This document discusses stress urinary incontinence (SUI) and various treatment options. It begins by outlining some myths about SUI, noting that it is not simply a natural part of aging and can be treated. Conservative management options for SUI are discussed such as lifestyle changes and pelvic floor exercises. Surgical options for urodynamic stress incontinence (USI) are then summarized, including traditional approaches like Burch colposuspension as well as modern mid-urethral sling (MUS) procedures. Complications, outcomes, and long-term results are compared for different surgical techniques. Guidance from regulatory bodies on the appropriate use of MUS is also presented.
Management of Female Urinary Incontinence (Urinary Leakage in Women in Delhi)Vijayant Govinda Gupta
This document summarizes female urinary incontinence, including definitions, types, prevalence, causes, investigations, grading, management, and surgical procedures. It defines stress urinary incontinence as the involuntary leakage of urine during exertion or sneezing. Conservative management includes lifestyle changes like pelvic floor exercises, weight loss, and medication. Surgical options for stress incontinence repair include sling procedures and colposuspension to suspend the bladder neck in a higher position. Complications of surgery can include injury, infection, and nerve damage. The takeaway messages are that urinary incontinence significantly impacts quality of life in women and effective long-term treatment involves both conservative and surgical options through collaboration with uro
Clinical approach to urinary incontinenceYasmin Saidat
This document discusses the definition, pharmacology, history taking, physical exam findings, investigations, and management of different types of urinary incontinence. It defines stress, urge, overflow, sensory, and bypass fistula incontinence. For each type, it describes the etiology, history, exam findings, investigation results, and management approaches including behavioral modifications, medications, injections, and surgeries. Key investigations discussed are urinalysis, bladder diary, urodynamic studies measuring post-void residual volume, uroflow, pressure flow studies, and cystometrogram. The goal of management is to treat any underlying causes and reduce symptoms through conservative or surgical methods depending on the incontinence type and severity.
Incontinence & Female Urology [Dr.Edmond Wong]Edmond Wong
The pad test is a test used to objectively measure urinary incontinence. It involves:
1. Having the patient wear a pre-weighed pad or diaper.
2. Having the patient drink a set amount of fluid, typically 500ml, and then engage in a set of exercises like walking, jumping, coughing over the next hour to provoke incontinence episodes.
3. Weighing the pad after 1 hour to determine the total amount of urine lost through incontinence during that time period.
4. A positive test result is typically considered to be more than 1 gram of urine lost, as anything less than that could be attributed to moisture rather than true incontinence.
This document discusses urodynamic testing procedures like uroflowmetry and cystometrogram that are used to evaluate lower urinary tract function and diagnose conditions like overactive bladder. It provides details on parameters measured and what different tests can reveal. Common urodynamic findings are defined, like detrusor overactivity and poor bladder compliance. Neurogenic causes of lower urinary tract dysfunction are outlined for different spinal cord injury levels. A step-wise approach to managing the neurogenic bladder is proposed starting with self-voiding and progressing to clean intermittent catheterization or other options if needed.
This document discusses various surgical methods for treating female stress urinary incontinence, including needle suspension procedures, retropubic colposuspension, pubovaginal slings, and mid-urethral slings. It covers the theories behind these approaches such as the pressure transmission theory and hammock hypothesis. For each method, it provides brief descriptions and highlights complications. Injection therapy is also summarized as a nonsurgical option that aims to improve the urethral seal through injections into the urethral tissues.
This document discusses the history and current state of urinary stress incontinence surgery. It covers the main theories around the pathophysiology of stress incontinence, including the hammock hypothesis and integral theory. A variety of surgical techniques are described that address stress incontinence by supporting the urethra or bladder neck, such as Burch colposuspension, transvaginal tape, and mid-urethral slings. The document also discusses drawbacks of different procedures and outcomes. Future treatments explored include stem cell therapy to regenerate pelvic floor muscles.
Management of Female Urinary Incontinence (Urinary Leakage in Women in Delhi)Vijayant Govinda Gupta
This document summarizes female urinary incontinence, including definitions, types, prevalence, causes, investigations, grading, management, and surgical procedures. It defines stress urinary incontinence as the involuntary leakage of urine during exertion or sneezing. Conservative management includes lifestyle changes like pelvic floor exercises, weight loss, and medication. Surgical options for stress incontinence repair include sling procedures and colposuspension to suspend the bladder neck in a higher position. Complications of surgery can include injury, infection, and nerve damage. The takeaway messages are that urinary incontinence significantly impacts quality of life in women and effective long-term treatment involves both conservative and surgical options through collaboration with uro
Clinical approach to urinary incontinenceYasmin Saidat
This document discusses the definition, pharmacology, history taking, physical exam findings, investigations, and management of different types of urinary incontinence. It defines stress, urge, overflow, sensory, and bypass fistula incontinence. For each type, it describes the etiology, history, exam findings, investigation results, and management approaches including behavioral modifications, medications, injections, and surgeries. Key investigations discussed are urinalysis, bladder diary, urodynamic studies measuring post-void residual volume, uroflow, pressure flow studies, and cystometrogram. The goal of management is to treat any underlying causes and reduce symptoms through conservative or surgical methods depending on the incontinence type and severity.
Incontinence & Female Urology [Dr.Edmond Wong]Edmond Wong
The pad test is a test used to objectively measure urinary incontinence. It involves:
1. Having the patient wear a pre-weighed pad or diaper.
2. Having the patient drink a set amount of fluid, typically 500ml, and then engage in a set of exercises like walking, jumping, coughing over the next hour to provoke incontinence episodes.
3. Weighing the pad after 1 hour to determine the total amount of urine lost through incontinence during that time period.
4. A positive test result is typically considered to be more than 1 gram of urine lost, as anything less than that could be attributed to moisture rather than true incontinence.
This document discusses urodynamic testing procedures like uroflowmetry and cystometrogram that are used to evaluate lower urinary tract function and diagnose conditions like overactive bladder. It provides details on parameters measured and what different tests can reveal. Common urodynamic findings are defined, like detrusor overactivity and poor bladder compliance. Neurogenic causes of lower urinary tract dysfunction are outlined for different spinal cord injury levels. A step-wise approach to managing the neurogenic bladder is proposed starting with self-voiding and progressing to clean intermittent catheterization or other options if needed.
This document discusses various surgical methods for treating female stress urinary incontinence, including needle suspension procedures, retropubic colposuspension, pubovaginal slings, and mid-urethral slings. It covers the theories behind these approaches such as the pressure transmission theory and hammock hypothesis. For each method, it provides brief descriptions and highlights complications. Injection therapy is also summarized as a nonsurgical option that aims to improve the urethral seal through injections into the urethral tissues.
This document discusses the history and current state of urinary stress incontinence surgery. It covers the main theories around the pathophysiology of stress incontinence, including the hammock hypothesis and integral theory. A variety of surgical techniques are described that address stress incontinence by supporting the urethra or bladder neck, such as Burch colposuspension, transvaginal tape, and mid-urethral slings. The document also discusses drawbacks of different procedures and outcomes. Future treatments explored include stem cell therapy to regenerate pelvic floor muscles.
This document provides an overview of overactive bladder, including its definition, etiology, pathophysiology, symptoms, diagnosis, and treatment. It defines overactive bladder as a symptom complex of urgency, usually with frequency and nocturia, with or without incontinence, in the absence of infection or other obvious pathology. The pathophysiology involves detrusor overactivity due to various hypotheses like outflow obstruction, neurogenic mechanisms, and myogenic and urothelial mechanisms. Treatment involves behavioral therapy, drug therapy using antimuscarinics, neuromodulation techniques, surgery for refractory cases, and newer developments in drug delivery and mechanisms of action.
1. Midurethral slings are now the gold standard treatment for stress urinary incontinence, replacing pubovaginal slings.
2. Pubovaginal slings are placed at the bladder neck and can be effective for various types of SUI but have higher risks than midurethral slings.
3. Midurethral slings are typically placed at the midurethra using either a retropubic or transobturator approach and have better subjective cure rates than pubovaginal slings.
Urinary incontinence can significantly impact one's quality of life by reducing self-esteem and independence. It becomes more common with age and depends on one's level of incontinence. Overflow incontinence specifically refers to the involuntary loss of urine due to overdistension of the bladder from an underactive or blocked bladder/urethra. Treatment involves surgically correcting any obstructions or using continuous catheter drainage for non-obstructive cases.
1. Urodynamics describes physiological tests used to investigate lower urinary tract function, with cystometry being the most important test. Cystometry measures pressure-volume relationships during bladder filling and voiding.
2. Urodynamics tests the storage and evacuation of urine to reproduce a patient's symptoms and determine their underlying cause. Tests include cystometry, uroflowmetry, and pressure-flow studies.
3. Urodynamics is indicated for incontinence, suspected outflow obstruction, neurogenic bladder dysfunction, and children with voiding issues. It helps characterize detrusor and bladder outlet function and diagnose neuropathies.
The document discusses overactive bladder (OAB) and its treatment. It defines OAB as a condition caused by involuntary bladder contractions resulting in urgency and frequent urination. Common causes include neurological issues, bladder problems, medications, and idiopathic factors. Treatment involves pharmacotherapy using anticholinergic drugs to suppress contractions, bladder retraining, or surgery in severe cases. Lifestyle changes like limiting caffeine and bladder retraining exercises can also help manage symptoms.
This document discusses female urinary incontinence. It begins by describing the functions of the urinary system and micturition cycle. It then discusses the different types of urinary incontinence including stress, urge, overflow and mixed incontinence. The document outlines the anatomy involved in maintaining continence like the urethral mechanism and Delancey's level II support. It also discusses various theories of continence. Treatment options covered include conservative treatments like pelvic floor exercises as well as surgical procedures for stress incontinence like vaginal slings and urethrocystopexy.
This document describes cutaneous urinary diversion, which involves creating an artificial opening in the skin for urinary elimination when the bladder has been removed or damaged. It defines urinary diversion and lists indications. It describes types of diversions based on elevation from the skin surface and shape. It discusses incontinent diversions like ileal conduits and continent diversions using techniques like Mitrofanoff appendicovesicostomy. Early and late complications of stomas are outlined, including ischemia, hemorrhage, stenosis, prolapse, hernia, and skin issues. Management strategies are provided for various complications that may arise.
This document discusses the management of urethral strictures. It defines urethral strictures and describes their etiology, including congenital causes and acquired causes like infection, inflammation, trauma, and iatrogenic factors. Treatment options for urethral strictures include instrumentation methods like dilation and internal urethrotomy as well as open reconstruction techniques like excision and anastomosis or substitution urethroplasty using grafts or flaps. The document provides details on various surgical techniques and factors that influence treatment outcomes.
This document discusses urodynamics, which involves testing to evaluate lower urinary tract symptoms. It describes the components of a urodynamic study including uroflowmetry, cystometrography, and pressure flow study. Common indications for urodynamics include evaluating young males with untreated LUTS, neurogenic bladder issues, and mixed urinary incontinence. The document outlines the procedure, parameters evaluated, normal values, and how urodynamics can help guide appropriate treatment.
This document provides an overview of overactive bladder (OAB). It defines OAB and its main symptoms of urgency, frequency, and nocturia. It discusses the prevalence of OAB increasing with age and being similar between genders. The document outlines the bladder anatomy and physiology, as well as theories around the etiology and pathophysiology of OAB. It describes the diagnosis and clinical evaluation of OAB through medical history, physical exam, urinalysis, and other tests. Finally, it covers treatment approaches for OAB including behavioral modifications, medications, injections, and surgeries.
This document discusses different types of megaureter, which is a dilated ureter greater than 8mm in diameter. It can be classified as primary (intrinsic to ureter) or secondary (reaction to external process). Primary obstructed megaureter is thought to be due to aperistalsis from increased collagen deposition. Refluxing megaureter results from a gaping ureteral orifice allowing reflux. Non-obstructing, non-refluxing megaureter may be due to high fetal urine output or delayed ureteral maturation. The document provides detailed anatomy and pathophysiology of different types of megaureter.
This document provides an overview of urodynamic studies (UDS), which are used to evaluate bladder storage and voiding functions. It describes various UDS techniques including uroflowmetry, post-void residual measurement, cystometry, and pressure-flow studies. Cystometry involves bladder filling while measuring pressures, and is used to assess capacity, compliance, and for detecting detrusor overactivity. Pressure-flow studies performed during voiding provide information about bladder contractility and outflow obstruction. Together these invasive UDS techniques provide valuable information to characterize lower urinary tract dysfunction.
The document provides information about overactive bladder, including its symptoms, causes, diagnosis, and treatment options. It defines overactive bladder as a group of urinary symptoms rather than a disease. The major symptom is a sudden urge to urinate that is difficult to delay. Causes include abnormal neurological signals between the bladder and brain that trigger emptying even when the bladder is not full. Treatments include behavioral changes, medications to relax the bladder muscle, Botox injections, and complex surgeries for severe cases.
This document discusses pubovaginal sling procedures for stress urinary incontinence. It provides background on the historical use of autologous materials for urethral suspension dating back to the early 1900s. Specific indications for fascial slings include loss or weakness of proximal urethral closure due to conditions like neurogenic bladder dysfunction or prior failed surgeries. The document describes patient evaluation, sling materials including autologous, allograft and xenograft tissues, and the surgical technique for pubovaginal sling placement including abdominal and vaginal dissection, sling passage and fixation, and post-operative care.
The document discusses the management of overactive bladder for gynecologists. It defines overactive bladder based on symptoms of urgency, with or without urge incontinence, usually with frequency and nocturia. It notes that overactive bladder significantly impacts quality of life through physical, psychological, social, sexual, and occupational problems. Treatment options include lifestyle changes, behavioral therapy, medications, minimally invasive procedures, and surgery. Common medications used are anticholinergic agents like trospium chloride, oxybutynin, tolterodine, solifenacin, and darifenacin.
Rational approach in management of hypospadias --Amilal Bhat
This document discusses the management of hypospadias and related conditions like chordee and penile torsion. It begins with an introduction to the topic of hypospadiology and lists various techniques that will be discussed, including chordee correction, torsion correction, the modified Tipu procedure, and others. The document then goes into detail on the techniques for correcting chordee and torsion while preserving the urethral plate, such as penile degloving, mobilization of tissues, and plication methods. Complications of other techniques are noted. Images demonstrate the surgical steps for correcting various cases. The talk aims to provide a rational approach for decision making in hypospadias repair.
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
PUJO is a restriction of urine flow from the renal pelvis to the ureter that can lead to renal deterioration if left uncorrected. It is a common cause of antenatally detected hydronephrosis, found in around 50% of cases. Obstruction causes progressive changes including renal pelvic and calyceal dilation, thinning of the renal cortex, interstitial fibrosis, and loss of renal function over time. Diagnosis involves renal ultrasound, voiding cystourethrogram, and diuretic renal scintigraphy to evaluate anatomy and function.
Vacuum Assisted Closure (VAC): A Promising Therapeutic Tool for Enterocutaneo...KETAN VAGHOLKAR
Managing an enterocutaneous fistula continues to pose the greatest challenge to the general surgeon. Aggressive supportive care is pivotal in managing these patients. Vacuum assisted closure (VAC) therapy is a promising therapeutic tool for such patients. It undoubtedly helps in closure of the fistula thus avoiding the high morbidity and mortality associated with surgical intervention. A case of a complex enterocutaneous fistula treated by VAC therapy is presented.
This document provides an overview of overactive bladder, including its definition, etiology, pathophysiology, symptoms, diagnosis, and treatment. It defines overactive bladder as a symptom complex of urgency, usually with frequency and nocturia, with or without incontinence, in the absence of infection or other obvious pathology. The pathophysiology involves detrusor overactivity due to various hypotheses like outflow obstruction, neurogenic mechanisms, and myogenic and urothelial mechanisms. Treatment involves behavioral therapy, drug therapy using antimuscarinics, neuromodulation techniques, surgery for refractory cases, and newer developments in drug delivery and mechanisms of action.
1. Midurethral slings are now the gold standard treatment for stress urinary incontinence, replacing pubovaginal slings.
2. Pubovaginal slings are placed at the bladder neck and can be effective for various types of SUI but have higher risks than midurethral slings.
3. Midurethral slings are typically placed at the midurethra using either a retropubic or transobturator approach and have better subjective cure rates than pubovaginal slings.
Urinary incontinence can significantly impact one's quality of life by reducing self-esteem and independence. It becomes more common with age and depends on one's level of incontinence. Overflow incontinence specifically refers to the involuntary loss of urine due to overdistension of the bladder from an underactive or blocked bladder/urethra. Treatment involves surgically correcting any obstructions or using continuous catheter drainage for non-obstructive cases.
1. Urodynamics describes physiological tests used to investigate lower urinary tract function, with cystometry being the most important test. Cystometry measures pressure-volume relationships during bladder filling and voiding.
2. Urodynamics tests the storage and evacuation of urine to reproduce a patient's symptoms and determine their underlying cause. Tests include cystometry, uroflowmetry, and pressure-flow studies.
3. Urodynamics is indicated for incontinence, suspected outflow obstruction, neurogenic bladder dysfunction, and children with voiding issues. It helps characterize detrusor and bladder outlet function and diagnose neuropathies.
The document discusses overactive bladder (OAB) and its treatment. It defines OAB as a condition caused by involuntary bladder contractions resulting in urgency and frequent urination. Common causes include neurological issues, bladder problems, medications, and idiopathic factors. Treatment involves pharmacotherapy using anticholinergic drugs to suppress contractions, bladder retraining, or surgery in severe cases. Lifestyle changes like limiting caffeine and bladder retraining exercises can also help manage symptoms.
This document discusses female urinary incontinence. It begins by describing the functions of the urinary system and micturition cycle. It then discusses the different types of urinary incontinence including stress, urge, overflow and mixed incontinence. The document outlines the anatomy involved in maintaining continence like the urethral mechanism and Delancey's level II support. It also discusses various theories of continence. Treatment options covered include conservative treatments like pelvic floor exercises as well as surgical procedures for stress incontinence like vaginal slings and urethrocystopexy.
This document describes cutaneous urinary diversion, which involves creating an artificial opening in the skin for urinary elimination when the bladder has been removed or damaged. It defines urinary diversion and lists indications. It describes types of diversions based on elevation from the skin surface and shape. It discusses incontinent diversions like ileal conduits and continent diversions using techniques like Mitrofanoff appendicovesicostomy. Early and late complications of stomas are outlined, including ischemia, hemorrhage, stenosis, prolapse, hernia, and skin issues. Management strategies are provided for various complications that may arise.
This document discusses the management of urethral strictures. It defines urethral strictures and describes their etiology, including congenital causes and acquired causes like infection, inflammation, trauma, and iatrogenic factors. Treatment options for urethral strictures include instrumentation methods like dilation and internal urethrotomy as well as open reconstruction techniques like excision and anastomosis or substitution urethroplasty using grafts or flaps. The document provides details on various surgical techniques and factors that influence treatment outcomes.
This document discusses urodynamics, which involves testing to evaluate lower urinary tract symptoms. It describes the components of a urodynamic study including uroflowmetry, cystometrography, and pressure flow study. Common indications for urodynamics include evaluating young males with untreated LUTS, neurogenic bladder issues, and mixed urinary incontinence. The document outlines the procedure, parameters evaluated, normal values, and how urodynamics can help guide appropriate treatment.
This document provides an overview of overactive bladder (OAB). It defines OAB and its main symptoms of urgency, frequency, and nocturia. It discusses the prevalence of OAB increasing with age and being similar between genders. The document outlines the bladder anatomy and physiology, as well as theories around the etiology and pathophysiology of OAB. It describes the diagnosis and clinical evaluation of OAB through medical history, physical exam, urinalysis, and other tests. Finally, it covers treatment approaches for OAB including behavioral modifications, medications, injections, and surgeries.
This document discusses different types of megaureter, which is a dilated ureter greater than 8mm in diameter. It can be classified as primary (intrinsic to ureter) or secondary (reaction to external process). Primary obstructed megaureter is thought to be due to aperistalsis from increased collagen deposition. Refluxing megaureter results from a gaping ureteral orifice allowing reflux. Non-obstructing, non-refluxing megaureter may be due to high fetal urine output or delayed ureteral maturation. The document provides detailed anatomy and pathophysiology of different types of megaureter.
This document provides an overview of urodynamic studies (UDS), which are used to evaluate bladder storage and voiding functions. It describes various UDS techniques including uroflowmetry, post-void residual measurement, cystometry, and pressure-flow studies. Cystometry involves bladder filling while measuring pressures, and is used to assess capacity, compliance, and for detecting detrusor overactivity. Pressure-flow studies performed during voiding provide information about bladder contractility and outflow obstruction. Together these invasive UDS techniques provide valuable information to characterize lower urinary tract dysfunction.
The document provides information about overactive bladder, including its symptoms, causes, diagnosis, and treatment options. It defines overactive bladder as a group of urinary symptoms rather than a disease. The major symptom is a sudden urge to urinate that is difficult to delay. Causes include abnormal neurological signals between the bladder and brain that trigger emptying even when the bladder is not full. Treatments include behavioral changes, medications to relax the bladder muscle, Botox injections, and complex surgeries for severe cases.
This document discusses pubovaginal sling procedures for stress urinary incontinence. It provides background on the historical use of autologous materials for urethral suspension dating back to the early 1900s. Specific indications for fascial slings include loss or weakness of proximal urethral closure due to conditions like neurogenic bladder dysfunction or prior failed surgeries. The document describes patient evaluation, sling materials including autologous, allograft and xenograft tissues, and the surgical technique for pubovaginal sling placement including abdominal and vaginal dissection, sling passage and fixation, and post-operative care.
The document discusses the management of overactive bladder for gynecologists. It defines overactive bladder based on symptoms of urgency, with or without urge incontinence, usually with frequency and nocturia. It notes that overactive bladder significantly impacts quality of life through physical, psychological, social, sexual, and occupational problems. Treatment options include lifestyle changes, behavioral therapy, medications, minimally invasive procedures, and surgery. Common medications used are anticholinergic agents like trospium chloride, oxybutynin, tolterodine, solifenacin, and darifenacin.
Rational approach in management of hypospadias --Amilal Bhat
This document discusses the management of hypospadias and related conditions like chordee and penile torsion. It begins with an introduction to the topic of hypospadiology and lists various techniques that will be discussed, including chordee correction, torsion correction, the modified Tipu procedure, and others. The document then goes into detail on the techniques for correcting chordee and torsion while preserving the urethral plate, such as penile degloving, mobilization of tissues, and plication methods. Complications of other techniques are noted. Images demonstrate the surgical steps for correcting various cases. The talk aims to provide a rational approach for decision making in hypospadias repair.
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
PUJO is a restriction of urine flow from the renal pelvis to the ureter that can lead to renal deterioration if left uncorrected. It is a common cause of antenatally detected hydronephrosis, found in around 50% of cases. Obstruction causes progressive changes including renal pelvic and calyceal dilation, thinning of the renal cortex, interstitial fibrosis, and loss of renal function over time. Diagnosis involves renal ultrasound, voiding cystourethrogram, and diuretic renal scintigraphy to evaluate anatomy and function.
Vacuum Assisted Closure (VAC): A Promising Therapeutic Tool for Enterocutaneo...KETAN VAGHOLKAR
Managing an enterocutaneous fistula continues to pose the greatest challenge to the general surgeon. Aggressive supportive care is pivotal in managing these patients. Vacuum assisted closure (VAC) therapy is a promising therapeutic tool for such patients. It undoubtedly helps in closure of the fistula thus avoiding the high morbidity and mortality associated with surgical intervention. A case of a complex enterocutaneous fistula treated by VAC therapy is presented.
This document discusses the history and benefits of gynaec endoscopic surgery, also known as minimal access surgery. It notes that minimal access surgery has revolutionized gynaecological surgery by allowing for less invasive procedures with reduced trauma through small incisions. While some simple procedures like treating ectopic pregnancies were adopted quickly, more advanced procedures required additional training. The document emphasizes the importance of training the next generation of gynaecologists to perform these surgeries safely and conferring the benefits of minimal access surgery broadly. It concludes by encouraging overcoming fears of new techniques and ensuring adequate structured training is provided.
1) The document reviews various incision and closure techniques used in obstetrics and gynecology, including transverse (e.g. Pfannenstiel), vertical (e.g. midline), and laparoscopic incisions.
2) It discusses factors to consider when selecting an incision such as patient characteristics, pathology, and risk of adhesions or malignancy. It also reviews various suturing and closure methods like continuous versus interrupted sutures.
3) The ideal closure method provides good approximation with minimal risk of complications like infection, hemorrhage or wound dehiscence while allowing for the best cosmetic outcome. Layered versus mass closure techniques are evaluated.
Major Randomized Controlled Trials in Surgery.pptxManoj95571
The document summarizes several major randomized controlled trials in surgery from the last 5 years. It covers trials related to appendicitis, hernia repair, breast cancer surgery, and upper gastrointestinal surgery. Some key findings include trials showing antibiotics are effective for uncomplicated appendicitis, mesh repair reduces hernia recurrence compared to suture repair, and intraoperative radiation during lumpectomy is comparable to external beam radiation for early breast cancer.
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
Postoperative adhesions by dr alka mukherjee nagpur m.s.alka mukherjee
Postoperative adhesions have become the most common complication of open or laparoscopic abdominal surgery and a source of major concern because of their potentially dramatic consequences. The proposed guideline is the beginning of a major campaign to enhance the awareness of adhesions and to provide surgeons with a reference guide to adhesion prevention adapted to the conditions of their daily practice. The risk of postoperative adhesions should be systematically discussed with any patient scheduled for open or laparoscopic abdominal surgery prior to obtaining her informed consent. Surgeons should adopt a routine adhesion reduction strategy with good surgical technique. Anti-adhesion agents are an additional option, especially in procedures with a high risk of adhesion formation, such as ovarian, endometriosis and tubal surgery and myomectomy. We conclude that good surgical practice is paramount to reduce adhesion formation and that anti-adhesion agents may contribute to adhesion prevention in certain cases.Any surgery in the abdomen can lead to adhesion formation and potential morbidity. There is evidence to support the use of hyaluronic acid derivatives, PEG based derivatives and solid barrier agents derived from oxidized regenerated cellulose, namely Interceed, during laparoscopy or laparotomy in benign gynaecological surgery to reduce the incidence, severity and proportion of adhesion formation. There is also evidence to support the use of hyaluronic acid derivatives during hysteroscopic surgery to reduce the incidence of intra–uterine adhesion formation. However, there is little evidence to support the use of pharmacological and hydrofloatation agents including Icodextrin in gynaecological surgery. There is no apparent benefit of using adhesion prevention agents at caesarean section. As most of the economic modelling is not based in contemporary health economies, further evidence is required before recommending anti–adhesion agents in current gynaecological practice.
This document summarizes developments in direct visual internal urethrotomy (DVIU) for treating urethral strictures. It discusses techniques for DVIU, factors that influence outcomes, and the long-term efficacy of DVIU. While initial studies reported high success rates of around 80%, more recent long-term studies have found much lower success rates of only around 8-30%. Recurrence rates are higher for longer strictures, greater spongiofibrosis, distal strictures, and when DVIU is repeated for recurrent strictures. Overall, DVIU has relatively poor long-term outcomes for treating urethral strictures.
Stent or No stent in renal transplant .pptxAkhilpradeep19
This document summarizes the findings of a systematic review on the use of ureteral stents during ureteroscopy for kidney stone treatment. The review found that stenting may reduce unplanned return visits, need for narcotics, ureteral stricture, and hospital readmission. However, stented individuals may experience more pain 4-30 days after surgery and stenting likely slightly increases operating time. Rates of urinary tract infection are probably similar between stented and unstented groups, but quality of life may be lower for stented individuals.
Dr Pawan Sharma1*, Dr D K Verma2, Dr Raj Kumar3
1General Surgeon Incharge, Civil Hospital Rohru, Shimla (HP), India
2Professor of Surgery, IGMC Shimla (HP), India
3General Surgeon Incharge, Distt Hospital Bilaspur (HP), India
*Address for Correspondence: Dr. Pawan Sharma, General Surgeon Incharge, Department of Surgery, Civil Hospital,
Rohru, Shimla, HP, India
Received: 17 September 2016/Revised: 11 October 2016/Accepted: 25 October 2016
ABSTRACT- This study was carried out to evaluate laparoscopic retroperitoneal ureterolithotomy (RPUL) as a viable
option to open surgical ureterolithotomy, laparoscopic transperitoneal ureterolithotomy (TPUL) & endoscopic urology and
to assess its place in the spectrum of alternatives for the surgical treatment of ureteric calculi in a tertiary care centre. This
study was conducted on 20 selected patients of single large impacted calculus of size more than 8mm in upper & middle
ureter. It was observed that excessive bleeding was present in only one (5%) of the patients, while need for conversion to
open ureterolithotomy was seen in 8 (40%) cases. No major peri-operative complications were encountered. From our
experience, it can be concluded that this procedure has definitely shown decreased post-operative discomfort, decreased
requirement of post-operative analgesia, better cosmesis, early return to work and less morbidity. RPUL can be considered
as another well-established armamentarium in the armour of laparoscopic surgeons and is recommended as an effective
minimally invasive primary treatment in large, impacted difficult stones in the upper & mid ureter.
Key-words- Retroperitoneal ureterolithotomy (RPUL), Transperitoneal ureterolithotomy (TPUL), Extracorporeal
shockwave lithotripsy (ESWL)
NOTES (Natural Orifice Transluminal Endoscopic Surgery) is an experimental surgical technique that performs operations through natural openings in the body without external incisions. This avoids scarring and reduces recovery time. NOTES procedures first began in the 1980s and have included cholecystectomies, appendectomies, and other abdominal surgeries. While still being developed, NOTES may eventually allow many operations to be done as outpatient procedures with even faster recovery times compared to laparoscopic surgery.
NOTES (Natural Orifice Transluminal Endoscopic Surgery)- By Dr. Onkardronkarsingh
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique that performs abdominal operations through natural orifices like the mouth, urethra, anus or vagina without external incisions. NOTES aims to reduce surgical trauma and pain for patients by avoiding incisions. It also shortens recovery time and eliminates risks of complications from external incisions like infections and hernias. While still in development, NOTES shows promise as a less invasive future of surgery.
This document discusses urinary tract injuries that can occur during laparoscopic gynecological surgery. It notes that bladder injury is the most common major complication. Prevention strategies include catheterization before trocar insertion, using the lowest effective power for electrosurgery, and identifying bladder boundaries. Injuries may be recognized intraoperatively through direct visualization, cystoscopy, or instilling dye. Postoperative recognition involves symptoms like pain and hematuria. Management often involves laparoscopic repair by a gynecologist or urologist to avoid additional morbidity of laparotomy.
This document discusses Natural Orifice Transluminal Endoscopic Surgery (NOTES), a new surgical technique. NOTES involves performing surgery using an endoscope inserted through natural openings like the mouth, vagina, or anus without external incisions. The document provides a brief history of NOTES, describes some procedures that have been performed, and discusses potential advantages as well as challenges to further development and acceptance of the technique.
esophageal cancer surgery types and complicationsved sah
Background-Anatomy & Staging
Surgical Candicate
Contraindication of sx
Assessment of patients for surgery
Approaches of esophagectomies
Esophageal reconstruction
Complications of esophagectomy
This study retrospectively reviewed 11 patients who underwent laparoscopic repair of large hiatal hernias with reinforcement of the diaphragmatic crura using various biologic grafts. Three different biologic grafts were used - acellular human dermal collagen in 6 patients, cellular porcine dermal implant in 1 patient, and porcine urinary bladder matrix in 4 patients. Outcomes were evaluated including perioperative data, complications, recurrence rates, and improvement in symptoms. The study found the laparoscopic repair of large hiatal hernias can be safely performed in rural hospitals using biologic grafts for crural reinforcement, with the choice of graft depending on availability, cost and surgeon preference.
Laparoscopy in obesity Dr.Nutan Jain Indiajainnutan
This document discusses obesity and minimally invasive surgery in gynecological procedures. It provides definitions of obesity, assessments for obese patients undergoing surgery, and techniques for laparoscopic surgery in obese patients. Key points include the use of longer instruments, perpendicular trocar insertion, and positioning to accommodate excess tissue. Minimally invasive surgery is shown to be as safe for obese patients as non-obese with proper precautions. It can significantly reduce morbidity compared to open surgery for procedures like hysterectomy and lymph node dissection in endometrial cancer.
Endoscopic ultrasound (EUS)-guided biliary interventions can be performed when endoscopic retrograde cholangiopancreatography (ERCP) fails or is not possible due to inaccessible papilla. Various EUS biliary drainage techniques exist with similar success rates but different risks of complications. EUS allows biliary access and stent placement via multiple routes without needing to access the papilla. The procedure involves using EUS to puncture and access the desired bile duct, placing a guidewire, dilating the tract if needed, and placing plastic or metal stents under endoscopy and fluoroscopy guidance. Success rates are high but risks include bleeding, bile leaks, cholangitis, and stent issues.
Similar to Urinary Stress Incontinence In Women (20)
This document discusses complications that can occur during and after hysteroscopy procedures. It begins by stating that the overall complication rate is around 2% according to studies. It then discusses specific direct complications like cervical injury, uterine perforation, hemorrhage, infection, and thermal damage. Indirect complications include reactions to anesthesia or distention media. The document provides details on managing three main complications - uterine perforation, hemorrhage, and injury to other organs like the bowel or bladder. It emphasizes the importance of proper training, experience, instruments and use of distention media like CO2 to reduce complications.
This document discusses the surgical management of menorrhagia (heavy menstrual bleeding). It begins by providing background information on menorrhagia, including that 12% of referrals to specialist clinics are for menorrhagia. It then discusses various causes of menorrhagia and guidelines for initial evaluation and treatment. The document focuses on different surgical treatment options for menorrhagia, including endometrial ablation techniques, myomectomy, and hysterectomy. It provides details on various ablation devices and techniques, and compares outcomes of ablation to hysterectomy. The document concludes by discussing potential future treatments for menorrhagia such as embolization of fibroids and medical therapies.
This document discusses various types of gynecological surgeries. It begins with an overview of pelvic anatomy and describes different surgical approaches including open, laparoscopic, vaginal, and robotic. Specific procedures covered include vulva surgeries like Bartholin cyst removal, hymenectomy, and vulvectomy. Vaginal procedures like anterior and posterior prolapse repair and vaginal hysterectomy are also outlined. The document then discusses cervical biopsies, colposcopies, and cerclage. Uterine conditions like fibroids, endometriosis, and cancers are reviewed along with their surgical management. Urinary incontinence procedures such as Burch colposuspension, slings, and inject
This document discusses the role of vaginal mesh in current practice for pelvic organ prolapse (POP) surgeries. It notes that while mesh has been successful in hernia repairs and is the gold standard for stress urinary incontinence surgeries, there is a lack of high-quality evidence supporting its routine use for POP. The document outlines various mesh types, surgical techniques, and complications reported with mesh including erosion, infection, pain, and new onset of issues like urinary or fecal incontinence. It recommends that mesh be used selectively and with informed patient consent given the risks, and that more research is needed to better define its role and safety in POP surgeries.
This document provides information on various aesthetic treatments and procedures that can be performed in urogynecology, including the use of lasers, fat transfer, and surgical techniques. It discusses factors contributing to interest in female genital cosmetic surgery, different treatment options and their applications, marketing terminology used, and ongoing studies evaluating techniques like laser therapy for conditions like genitourinary syndrome of menopause. Professional opinions emphasizing the lack of evidence for some procedures and need for informed consent are also presented.
This document discusses various techniques to prevent vaginal vault prolapse after hysterectomy. It begins by defining vaginal vault prolapse and reviewing its reported incidence following different types of hysterectomy. It then examines evidence and techniques for preventing vault prolapse when performing abdominal hysterectomy, including re-anchoring the uterosacral ligaments during vault closure. For vaginal hysterectomy, it reviews evidence that McCall's culdoplasty technique may reduce posterior-apical prolapse compared to other closure methods. For laparoscopic hysterectomy, it discusses incising the vaginal cuff above pelvic supports and suturing the uterosacral ligaments laparoscopically. The document concludes by recommending uter
This document discusses various tubo-ovarian pathologies that can be identified on ultrasound scanning, including ovarian tumors, tubo-ovarian abscesses, pelvic inflammatory disease, and others. It provides details on the ultrasound appearance of different types of ovarian cysts and tumors such as dermoid cysts, endometriomas, and various benign and malignant solid masses. Simple rules are outlined to help differentiate between benign and malignant ovarian tumors based on ultrasound features. The importance of correlating ultrasound findings with clinical history, examination, and other tests is emphasized, as ultrasound alone cannot always definitively diagnose whether a mass is benign or malignant.
This document discusses the management of dysfunctional uterine bleeding (AUB/HMB) in teenage girls. It notes that AUB is common in adolescents due to anovulatory cycles from an immature hypothalamic-pituitary-ovarian axis. The most common cause of AUB in adolescents is anovulation. It recommends evaluating adolescents with AUB for common causes using the PALM-COEIN classification system and investigating further if bleeding occurs less than 21 days or more than 35 days between cycles. Treatment involves treating any underlying causes, maintaining hemodynamic stability, correcting anemia, and using hormonal contraceptives or progesterone to regulate cycles and prevent recurrence in mild to moderate cases. More severe cases may require additional
This document discusses obstetric anal sphincter injuries (OASIS), including its prevalence, risk factors, prevention strategies, and consequences of missed diagnoses. OASIS occurs in 0.5-2.5% of vaginal deliveries and can lead to fecal incontinence and long-term pelvic floor issues. Risk factors include midline episiotomy, prolonged second stage of labor, forceps delivery, and nulliparity. Prevention strategies focus on modifiable factors like restrictive episiotomy, perineal protection, warm compresses, and positions during delivery. Proper diagnosis and repair are also important to reduce short and long-term morbidity. Training and documentation are crucial to prevent missed
Anaemia is common in pregnancy and can have serious consequences for both mother and baby if left untreated. The document discusses the causes, signs, and treatments of anaemia in pregnancy. It notes that the most common cause is iron deficiency, and recommends daily supplementation with 100mg of elemental iron and 300μg of folic acid during pregnancy to prevent anaemia. For treatment, oral iron is usually sufficient for mild to moderate cases, while intravenous iron or injections are used if oral intake is unreliable or not tolerated. Close monitoring of haemoglobin levels is important both during and after pregnancy to promptly treat any anaemia.
This document discusses cardiac disease in pregnancy. It notes that cardiac disease affects 1-2% of pregnancies and is a leading cause of maternal mortality. Rheumatic heart disease is the most common in many countries. Physiological changes in pregnancy like increased cardiac output place extra burden on the heart. Close monitoring and management of cardiac patients is needed before, during and after pregnancy to optimize outcomes for both mother and baby. A multidisciplinary team approach is important for treating women with heart disease through pregnancy.
Women experience various vulvo-vaginal and sexual problems as they age, such as urinary incontinence and prolapse surgery. Many women seek cosmetic surgery to improve their appearance and self-esteem, including procedures on their genitals like labiaplasty. Cosmetic genital procedures aim to address physical discomfort, abnormal appearances, and sexual issues. They include labiaplasty to reduce enlarged labia, vaginoplasty to address conditions like a narrow or absent vagina, and laser therapy to tighten the vagina. The goal of these emerging cosmetic surgeries is to help women experience improved quality of life and sexual gratification as they age.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
1. DATO‘ DR ARUKU NAIDU
MD(UKM), FRCOG(LONDON), CU(JCU), AM
CONSULTANT UROGYNAECOLOGIST
HRPB. ISH
www.aruku-naidu.blogspotcom
STRESS URINARY
INCONTINENCE
2. ― The involuntary loss of
urine so severe as to have a
significant cause of disability and
dependancy ‖
It affects quality of life
tremendously.
URINARY STRESS
INCONTINENCE
3. Urinary incontinence/prolapse
is a natural part of aging
Norm
Nothing can be done about it
Surgery is the only solution
Knowledge limits lead to
patients accepting
Shyness
MYTHS
4.
5.
6. Impact on lifestyle and avoidance
of activities
Fear of losing bladder control
Embarrassment
Impact on relationships
Increased dependence on
caregivers
Discomfort and skin irritation
Long run—cost & depression
QUALITY OF LIFE IMPACT
7. COST OF INCONTINENCE
• DIRECT, INDIRECT AND TOTAL COSTS
• 2% GDP IN US AND SWEDEN
• 1 BILLION IN AUSTRALIA
• 386 DOLLARS PER YEAR PER
• INCONTINENT PATIENT
• 710 MILLION DIRECT COSTS PER YEAR
• Malaysia ?? Started 2005, adhoc budget
• MORE SCHOLASHIPS & UROGYNAE UNITS
• IKN
9. . Lifestyle interventions
. Avoid bladder irritants
. Bladder Diary
. Postural Techniques: perfect pee!!
. Physiotherapy & Pelvic Floor Exercise depending on PM
strength 60-70% improvement
(Effect of Kegel Exercises on the Management of Female Stress Urinary Incontinence: A
Systematic Review of Randomized Controlled Trials British Journal of Urology (1998), 82, 181–191)
. Topical estrogens for every woman over 45 years
CONSERVATIVE MANAGEMENT
10.
11. STRESS URINARY INCONTINENCE
NON MEDICAL/SURGICAL MANAGEMENT
Don‘t forget adjuvant non medical treatment which can
greatly improve patient‘s quality of life
What is available?
Pads and pants
Devices (and appliances)
Aides
Indwelling catheters
Intermittent catheterisation (CISC)
13. TRADITIONAL VS MODERN
URODYNAMIC STRESS INCONTINENCE
TRADITIONAL SURGICAL
APPROACH:
• Elevate bladder neck &
proximal urethra
• Support bladder neck &
prevent funneling
• Increase outflow
resistance
• Colposuspension
MODERN SURGICAL
APPROACH:
• ―Intergral Teory‖ of urinary
incontinence
• Proposes that urinary incontinence
are as a result of failure urethral
closure by pubourethral ligament,
suburethral hammock &
pubococcygeus muscles to support
the mid-urethra
• Mid-urethral slings
18. Historacilly colposuspension has been regarded as most
likely to produce a lasting cure and correction of
cystocoele
Long term results; 85-90% cure at more than 10 years
10% rectocele
10% ‗de novo‘ overactive bladder(OAB)
SO WHY CHANGE TO NEW PROCEDURES;
Surgical cure < 100%
Complications: voiding dysfunction/OAB
Recover time longer
Expensive
URINARY STRESS INCONTINENCE
23. 90 women, TVT as primary
procedure for USI
Median follow up 11.5 years (69/90)
90.2% objectively cured
77% Subjectively cured (Pt
Impression scale)
4.7% considered failed
Of 25 with preoperatively urgency,
56% reported improvement
5.9% de novo urge symptoms
Nilsson et al (2001, 2008), Nordic multi-
centred prospective study
TVT MEDIUM TO LONG TERM RESULTS
TVT 17 years duration , high
satisfaction rate & no serious
long term complications
35. Ward, Hilton (BMJ 2002, 2007)
UK & Ireland TVT Trial Group
Multicentre RCT, 2 and 5 year outcome
175 patients with TVT, 169 patients with colposuspension
Objective cure rate 81% (MUS) vs 90% ( colposuspension)
TVT is associated with more operative complications than
colposuspension, but colposuspension is associated with more
postoperative complications and longer recovery
TVT shows promise for the treatment of USI b/c of minimal access &
rapid recovery
Cure rates at 6 months, 2 years and 5 years comparable btw 2 groups
MUS more cost effective
MUS VS COLPOSUSPENSION
36. Richter HE, Albo ME, Zyczynski HM, et al. Retropubic versus transobturator midurethral slings for stress
incontinence.
N Engl J Med 2010;362:2066-76
Trial Of Mid-Urethral Slings
TOMUS
RP vs TO – overall: objective SUI cure rates ( 81% vs 78%)
37. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic
suburethral sling operations for stress urinary incontinence in
women. Cochrane Database of Systematic Reviews 2011, 62 trials
( 7101 patients)
RP vs TO – overall: equivalent subjective SUI cure rates
TO – less voiding dysfx, blood loss, bladder perforation, shorter
op time
RP vs TO – overall: objective SUI cure rates ( 88% vs 84%)
38. Complications TVT TOT
Bladder perforation 2 0
Vaginal skin perforation 0 4
Groin pain 1 8
Removal of tape (pain) 0 1
Tape extrusion 2 3
Removal for extrusion 0 1
Voiding difficulty requiring
catheterization
5 5
Requiring ISC at 4/52 3 4
Requiring ISC at 1 year 1 2
UTI requiring antibiotics 7 2
De novo OAB symptoms 4 4
Wound infections 0 2
Vaginal infections 0 4
COMPLICATIONS
39. Management of mesh complication after SUI & POP repair: A review & analysis of current literatures. Barski &
Deng. BioMed Research International, volume 2015, Article ID 831285, 8 pages
40. Market driven: see one & do culture
Tips : stay away from the bladder neck, do
the sling that you are trained in
If you want to change – LEARN IT properly
MUS are unforgiving with a small margin for
error
More ‗art‘ in the surgery? practice
Need to be ‗tentioned‘ as comes with
experience
Handle complication early & effectively
WHAT LEADS TO COMPLICATIONS
41.
42. # 100. Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term
Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress
Urinary Incontinence. JAMA. 2018 Oct 23. 320 (16):1659-1669.
43. Gurol-Urganci I, Geary RS, Mamza JB, Duckett J, El-Hamamsy D, Dolan L, et al. Long-term Rate of
Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress
Urinary Incontinence. JAMA. 2018 Oct 23. 320 (16):1659-1669.
44. Surgeon
Training
Knowledge
Skills
Devices
Mesh Type
Route of application
Patient
LUTs ISD, DO, VD
POP, concurrent Ant Mesh
Age
Pregnancy
Obesity
Governing Body ??
Cochrane Reviews
College Guidance
Industry modification – laser cut,
detangled edges, handles, string,
adjustability
Efficacy
Complications / functional LUTs
Previous failed
Fistula radiation
Interactions of factors influencing choice/risk
46. Mid-urethral mesh sling procedures
1.5.2 If non-surgical management for stress urinary incontinence has failed, and
the woman wishes to think about a surgical procedure, offer her the choice of:
colposuspension (open or laparoscopic) or an autologous rectus fascial sling.
Also include the option of a retropubic mid-urethral mesh sling in this choice
but see recommendations 1.5.7 to 1.5.11 for additional guidance on the use of
mid-urethral mesh sling procedures for stress urinary incontinence. [2019]
1.5.7 When offering a retropubic mid-urethral mesh sling, advise the woman
that it is a permanent implant and complete removal might not be possible.
[2019]
1.5.8 If a retropubic mid-urethral mesh sling is inserted, give the woman
written information about the implant, including its name, manufacturer, date
of insertion, and the implanting surgeon's name and contact details. [2019]
1.5.9 When planning a retropubic mid-urethral mesh sling procedure, surgeons
should: use a device manufactured from type 1 macroporous polypropylene mesh
consider using a retropubic mid-urethral mesh sling coloured for high visibility,
for ease of insertion and revision. [2013, amended 2019]
1.5.10 Do not offer a transobturator approach unless there are specific clinical
circumstances (for example, previous pelvic procedures) in which the
retropubic approach should be avoided. [2019]
1.5.11 Do not use the 'top-down' retropubic mid-urethral mesh sling approach or
single-incision sub-urethral short mesh sling insertion except as part of a
clinical trial. [2019]
47. Careful selection of patient and pre-op optimization
Appropriate & adequacy of training received prior to operating
Treat UTI prior to surgery if present
Urodynamic assessment pre-operatively as indicated
Careful decision on choice of approach after thorough
evaluation of patient‘s LUTS
Proper positioning of the patient before embarking on the
surgery
Emptying of bladder before commencing the surgery
Consider autologous sling which may be deemed a safer
alternative than a synthetic sling at the time of urethral injury
Discuss all options & patients involved in decision making
REMEDIAL MEASURES TO
OVERCOME COMPLICATIONS?
54. CONSENT FOR SLINGS
2. Possible serious risks:
Damage to the bladder and/or Ureter, Urethra and/or long term disturbance to the bladder function in approximately 2% of cases
Damage to bowel ( anus, rectum small or large bowels) in approximately in 1% cases
Haemorrhage requiring blodd transfusion in about 2-3% cases
Return to the operating theatre for additional stitches or to control bleeding or for open surgery
Pelvic abscess/infection approximately in 1% cases
Venous thrombosis or pulmonary embolism approximately in 1% patients
Dyspareunia ( painful sexual intercourse)
Failure to achieve the desired results or recurrence of prolapse or urinary incontinence
Mesh Sling/MUS /tape: MESH SLING IS PERMANENT & IT IS NOT POSSIBLE TO REMOVE COMPLETELY IF NEED ARAISES
Complications- eg. Erosions, mesh protrusion in about (0.7%) , voiding dysfunction/difficulty in voiding ( 3%) , pelvic or groin pains, damage to urethra.
Others (please specify) ______________________________________________________________________________________________________
3.Possible frequently occurring risks:
Urinary retention in about 3% of patients, may need release or excision of the tape/ mesh sling
Vaginal bleeding, discharge or infection
Frequency of micturition, nocturia and urgency in about 7% of patients
Wound infection – up to 15% especially in patients with risk factors
Pain, may require analgesics- in particular Pelvic/groin pain is TOT mesh sling is applied, the pain can last for months to years in very few patients
Others (please specify) ______________________________________________________________________________________________________
4. Any extra emergency procedures which may become necessary during the procedure:
Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure
Removal of ovaries for unsuspected disease during the surgery
Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder, ureter, bowel or major blood vessels in
approximately in 4% - 8% cases
Other procedures may be necessary to save live or to overcome complications (please specify) ____________________________________________
I have explained that in obese women, those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the
quoted risks may be higher than average women.
I have also discussed the benefits and risks of any other available treatments including Physiotherapy, Conservative & Non Surgical options.
I have discussed other alternative surgeries to correct SUI/USI such as colposuspension, fascial slings, synthetic slings (MUS) & bulking
agents
Sling controversy discussed / Global statement supporting MUS for SUI 2018, discussed (https://www.augs.org/assets/1/6/AUGS-
SUFU_MUS_Position_Statement.pdf)
55. SUS IS GOLD STANDARD FOR NOW ??
• Mid urethral sling(MUS) operation is easy, simple and cost
effective operation
• MUS more cost effective than Burch colposuspension. SUS are
costly per tape.
• Subjective and Objective cure somewhat same. Ward et al
2002, 2004 and 2007.
• 17 years of TVT experience ( Nilssion et al 2013)
• Choice of RP or TO need individual assessment & preference
• Other options need to discussed with patients
• Obtain informed consent if doing MUS procedures
• Change of practice is inevitable
• May need to learn colposuspension back !!
• May need to explore newer modality ??
CONCLUSIONS