What the radiologists should know about US and MR findings of female urinary incontinence surgical tapes.

Transcription

1 What the radiologists should know about US and MR findings of female urinary incontinence surgical tapes. Poster No.: C-0744 Congress: ECR 2017 Type: Educational Exhibit Authors: T. Robba, L. Squintone, S. Robiati, A. Gallo, D. D'Ascoli, M C. Dotto, R. Carone, A. Borre ; Turin/IT, Torino/IT, Torino (TO)/IT Keywords: Pelvic floor dysfunction, Surgery, Diagnostic procedure, Ultrasound, MR, Urinary Tract / Bladder, Pelvis, Abdomen DOI: /ecr2017/C-0744 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 32

2 Learning objectives to make the radiologists more confident with some surgical approaches (injectable bulking agents and sling procedures) for female stress urinary incontinence. Background The urinary incontinence (UI) is one of the most common conditions in the female population that causes significant anxiety and negatively affect the quality of life (1). The primary types of UI include: stress incontinence (SUI): urine loss during physical activity that increases abdominal pressure such as sneezing (urethral sphincter deficiency); urge incontinence: urine loss with urgent need to void due to involuntary bladder contraction (detrusor overactivity) mixed:both stress and urge incontinence; overflow incontinence: with constant dribbling of urine and bladder incompletely emptying (2). According a traditional old classification proposed by Blaivas, stress urinary incontinence (SUI) was subdivided into three separate categories: SUI type I: absence of urethral hypermobility; SUI type II: urethral hypermobility (UH); SUI type III: intrinsic sphincter deficiency- ISD (urodynamic diagnosis). For patients who are unable to achieve improvement in their symptoms through lifestyle modifications, surgical intervention can be considered as an alternative (3): SUI type I: intra/extraurethral bulking therapy SUI type II: with a retropubic approach (RP-TVT: retropubic tension-free vaginal tape) or transobturator approach (TO-TVT: transobturatortensionfree vaginal tape) SUI type III: mid-urethral sling eventually associated with bulking therapy (more likely failure) myself x600 Normal 0 false false false IT JA X-NONE Currently this simple categorisation is out of date, since we are now approaching a new concept about the Pathophysiology of stress urinary incontinence which integrate Page 2 of 32

3 hypermobility and urethral dysfunction as inter-related elements. In the majority of incontinent women both conditions coexist. But the presence/absence of hypermobility is important to to decide a treatment option. Urinary continence is supplied by three subsystems (fig. 1): urethral sphinteric system fascial support chiedere a Squintone quali legamenti e fasce levator muscle support: intermediate pelvic diaphragm (ischiococcigeal muscle and elevator ani muscle - pubo-rectal, pubo-coccigeal, ileococcigeus components) urogenital diaphragm (fig. 2) In normal conditions there is a normal rotational mobility of the urethra, seen at ultrasound evaluation as an increase of 25 of the pubo-urethral angle during straining (fig. 3). In case of SUI with urethral hypermobility (type 2) mid-urethral slings are recommended as the first-line surgical treatment. Tension-free vaginal tape may be entered with retropubical (RP-TVT) or transobturator approach (TO-TVT) (fig. 4). In US the tape can be seen as a hyperechogenic structure underneath the midurethra. Sonographic Classification of Tape Behavior was used for categorizing into 3 groups by dynamic tape change observed: - group I: at rest the tape lies paraller to the urethral lumen, during Valsava the tape becomes c- shaped; - group II: both at rest and during Valsalva the tap runs parallel to the urethral lumen; - group III: already at rest the tape is c-shaped and during Valsava this curved is maintained (fig. 5) (4). In case of SUI with absence of urethral hypermobility (type 1) (fig. 6) or less likely in case of intrinsic sphincter deficiency (SUI type 3) the therapeutic approach is the intraurethral or peri-urethral injection of bulking agents (fig. 7). Transvaginal MESH is a polipropylene net-like implant used to treat pelvic organ prolapse and stress urinary incontinence in women (fig. 8). Page 3 of 32

4 Images for this section: Fig. 1: Three systems of urinary continence Page 4 of 32

5 Fig. 2: pelvic floor anatomy Netter Page 5 of 32

6 Fig. 3: mobility of the urethra Page 6 of 32

7 Fig. 4: Tension-free vaginal tape Page 7 of 32

8 Fig. 5: Diagram of the tension-free vaginal tape (TVT) position relative to the percent urethral length and distance of the tape from the urethral lumen. B, bladder; BN, bladder neck; S, symphysis pubis; A, shortest distance of the tape from the urethral lumen; L, percent urethral length relative to the midpoint of the tape. bibliografia Jacek Kociszewski, et al. Tape Functionality: Sonographic Tape Characteristics and Outcome After TVT Incontinence Surgery Neurourology and Urodynamics 27: (2008) Page 8 of 32

9 Fig. 6: absence of urethral hypermobility Page 9 of 32

10 Fig. 7: Intra-urethral or peri-urethral bulking agents Page 10 of 32

11 Fig. 8: Transvaginal Mesh sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahukewjiufbuptqahvioxqkhs4zc3sqjrwibw&url=http%3a%2f%2fwww.urology-textbook.com %2Fstress-urinary-incontinencetreatment.html&psig=AFQjCNGdN4kd7mqlm5GqZxNZ4_VtHJ733g&ust= Page 11 of 32

12 Findings and procedure details CASE 1: a 64 years old patient with traumatic failure of RP-TVT. In 2012 a RP-TVT was applied for SUI. The patient fell to the ground six months ago and complained again stress urinary incontinence. US show the left arm of RP-TVT collapsed and surrounded by edema (fig. 9). Pelvic floor MRI was performed three months after and the edema was resolved. The left arm still appear disrupted (fig. 10 and fig.11), while the right arm was normal in fig.12. CASE 2: a 70 years old patient with recurrent urinary incontinence (in 1998 osteosynthesis was performed with gamma-nail for femural neck fracture; in 2008 intraurethral Macroplastique bulking was done with subsequent left paraurethral abscess; in 2012 TO-TVT was applied). Fig. 13 and 14: on the right side Macroplastique extends properly along the urethra (red arrow), while on the left a small residual component is seen (yellow arrow). In fig. 15 the red asterisk indicates external and internal obturator muscles, while in fig. 16 the red asterisk points out obturator fat hernia. In fig. 17 only the right arm of TO-TVT is properly seen closed to obturator muscles. In fig. 18 coronal view shows the normal right arm of TO-TVT (red asterisk), while the left arm is almost collapsed (red hexagon). As also seen in the previous images, the external and internal obturator muscles are hypothrophic and the fig. 19 the tendineous arc is deflected. This damage of supportive musculo-tendineous structures may have contributed to TO-TVT failure. CASE 3: a 62 years old women who undewent (2014) to an anterior elevate (MESH) for anterior prolapse. In 2012 a RP-TVT was removed because of for vaginal erosion. In this fat-sat image a large area of bone marrow edema (red arrow) is still seen at the left superior pubis ramus where the left arm of the RP-TVT were inserted (fig. 20). In fig. 21 and in fig. 22 both arms of the anterior elevate extend from urethra and vaginal walls to the ischiatic spines (fig. 23). CASE 4: a 46 years old patient underwent to TO-TVT for SIU in 2012 with secondary urinary retention. An attempt of loosening of the tape was done. After that the urinary incontinence recurred (2014) and an unsuccessful intraurethral injection of bulking agents was performed. Ultrasounds show deflection of the right arm of TO-TVT (fig. 24), while in fig. 25 the left arm is still appreciable at MRI. In fig. 26, fig. 27, fig. 28 and fig. 29 the tendinous arc and the levator ani muscle are scarcely noticeable (red arrows) and intraurethral bulking injection is showed (red star). Page 12 of 32

13 Images for this section: Fig. 9: Case 1: US show the left arm of RP-TVT collapsed and surrounded by edema Page 13 of 32

14 Fig. 10: Case 1: at coronal TSE T2 the left arm of RP-TVT still appear disrupted Page 14 of 32

15 Fig. 11: Case 1: at sagittal TSE T2 the left arm of RP-TVT appear disrupted Page 15 of 32

16 Fig. 12: Case 1: the right arm of RP-TVT was normal Page 16 of 32

17 Fig. 13: Case 2: on the right side the injected Macroplastique extends properly along the urethra (red arrow), while on the left a small residual component is seen (yellow arrow) Page 17 of 32

18 Fig. 14: Case 2: on the right side Macroplastique extends properly along the urethra (red arrow), while on the left a small residual component is seen (yellow arrow. An obturator fat hernia is also seen. Page 18 of 32

19 Fig. 15: Case 2: the red asterisk indicates external and internal obturator muscles Page 19 of 32

20 Fig. 16: Case 2: the red asterisk indicates external and internal obturator muscles, while the red asterisk points out obturator fat hernia. Fig. 17: Case 2: only the right arm of TO-TVT is properly seen closed to obturator muscles. Page 20 of 32

21 Fig. 18: Case 2: coronal view shows the normal right arm of TO-TVT (red asterisk), while the left arm is almost collapsed (red hexagon) Page 21 of 32

22 Fig. 19: Case 2: the tendineous arc is deflected Page 22 of 32

23 Fig. 20: Case 3: a large area of bone marrow edema (red arrow) is still seen at the left superior pubis ramus where the left arm of the RP-TVT were inserted (now removed) Page 23 of 32

24 Fig. 21 Page 24 of 32

25 Fig. 22: Case 3: both arms of the anterior elevate extend from urethra and vaginal walls to the ischiatic spines. Page 25 of 32

26 Fig. 23: Case 3: both arms of the anterior elevate extend from urethra and vaginal walls to the ischiatic spines. Page 26 of 32

27 Fig. 24: Case 4: ultrasounds show deflection of the right arm of TO-TVT Page 27 of 32

28 Fig. 25: Case 4: the left arm of the TO-TVT is still appreciable at MRI Fig. 26: Case 4: the tendinous arc and the levator ani muscle are scarcely noticeable (red arrows) and intraurethral bulking injection is showed (red star). Page 28 of 32

29 Fig. 27: Case 4: the tendinous arc and the levator ani muscle are scarcely noticeable (red arrows) and intraurethral bulking injection is showed (red star). Page 29 of 32

30 Fig. 29: Case 4: the tendinous arc and the levator ani muscle are scarcely noticeable (red arrows). Page 30 of 32

31 Fig. 28: Case 4: the intraurethral bulking injection is showed (red star). Page 31 of 32

32 Conclusion Normal 0 14 false false false IT X-NONE X-NONE Personal information References Katarzyna J. Macura, MD, PhD, Rene R. Genadry, MD and David A. Bluemke, MD, PhD MR Imaging of the Female Urethra and Supporting Ligamentsin Assessment of Urinary Incontinence: Spectrum of Abnormalities. RadioGraphics 2006;26:113. Katarzyna J. Macura, Rene R. Genadry. Female urinary incontinence: pathophysiology, methods of evaluation and role of MR imaging. AbdomImaging (2008) 33: Brian C. Jung,Ngoc-Anh Tran,SadhnaVerma, Rahul Dutta, Paul Tung, Michael Mousa, Eduardo Hernandez-Rangel, MeghaNayyar, ChandanaLall. Cross-sectional imaging following surgicalinterventions for stress urinary incontinencein females. AbdominalRadiology (2016) 41: Jacek Kociszewski et al. Tape Functionality: Sonographic Tape Characteristics and Outcome After TVT Incontinence. Neuroulogy and Urodynamics 27: (2008). Page 32 of 32