BSUG Annual scientific update 5/6 th Nov 2012 Zainab Khan SWIG 4/12/2012
New developments in drug therapy B3 Agonists: Mirabegron - FDA approval - Mirabegron (50 &100mg) vs tolterodine 4mg- similar efficacy, no dry mouth Botox A: constipation Khullar et al in press 2012 Doses of 100 and 150iu provide appropriate risk/benefit balance Chapple et al ICS 2012 Relax study- 200iu, 1/3 rd patients ISC tincello et al Euro Urol 2012 Chris Chapple
Conservative Therapy Life style interventions Physical therapies: PFMT vs no treatment Cones vs PFMT PTNS PTNS vs oxybutynin+ PTNS- equal Most data limited to case series- inadequate NICE Recommendations for PFMT: 8 contractions *3 times daily* 3 months Simon Hill
Painful bladder IC (NIDDK criteria) CPPS IC/PBS(2006) chronic pain related to bladder+ one other symptom + exclusion of confusable diseases History, examination, MSU, bladder diary (all voids< 350= PBS likely UD and Cystoscopy) Urodynamics: sensation(<150) capacity(<350) Doug Tincelle
Treatment: pain control, patient support, intravesical therapy Distension DMSO (90% response; 40% relapse) Hyaluronic acid (30-70%) Botox- non RCT data- 75% improve, 75% relapse by 6 month. Oral therapy (cimetidine, pentosan polysulphate, amitryptaline, cyclosporin A)
Neuromodulation in DGH OAB, non-obstructive voiding dysfunction Need for change, barriers, cost effectiveness (QALYs at 10yrs> Botox, drugs) Challenges: procedure, service, funding Evidence: Cochrane 2009, 8RCT (50% complete continence, 87% improvement) Aethele Khunda
Urethral Diverticulae Incidence: 1-5% Cong, Acquired History: dysuria, dribbling, dysparenia Examination: palpable lump, expressable discharge Investigation: MRI, VCMG Principles of treatment Risk of cancer Controversies T Greenwell
Nocturia Definition, prevalence Pathophysiology: sleep disorders, nocturnal polyuria (NPI>33% 65 yrs, 20% in younger), 24 hrs polyuria(>40ml/kg/day), reduced bladder capacity Hx, Exam, Urine, QOL, bladder diary, renal function, glucose Management: systemic disease, advice- fluid, diuretics, antidiuretic Estrogen, Botox, Imipramine H Hashim
Surgery for urinary incontinence in the elderly 51% consultations +70, 16% surgery Aging urethra, acute and chronic retention Consider same steps: physio, UD, surgery Vaginal atrophy Surgery for SUI: Bulkers vs tapes Tapes issues: <65 yr vs >65 yr 80% vs 67%» Mortality/morbidity similar to major non-cardiac surgery» Women >70 yrs, 13% retention, far superior QOL scores» Mini-tapes Karen Gurrero
What we have learned from the mesh debate Trends in gynae surgery( 16% hysterectomy, 37% prolapse surgery) UK prolapse survey (2011) 56% recurrent and 11% primary procedure Why use mesh, Types Class action in USA, Meshed up mesh Biocompatibility, resistance to infection, rapid fibrin fixation, host tissue incorporation 2010: MHRA- 42 adverse effects tapes 2008-2010: FDA- 2874(1503-POP; 1371- tape) 2011: FDA - systemic review of the published scientific literature 1996-2011 No evidence that TV mesh to support apical and post wall provides more benefit than traditional repair Ant mesh may provide better anatomical support but that doesn t reflect in better symptomatic results. Chris Mayne, David Richmond
Recurrence: Evidence base for salvage incontinence surgery obesity, poor tissues Urge incontinence Points to consider: Urethral hpermobility, ISD Sling wrongly positioned, too loose Mobility of urethra, Position of bladder neck (Type 3 SUI on VU), DO, prolapse, age VLLP(<60- ISD, >90 hypermobility) UPP (poor reproducibility, no correlation to surgical outcome, MUCP<20-only independent factor to predict failure ) Roland Morley
Conflicting evidence -effectiveness of 2 nd -line retropubic slings Studies on TVT outcome- 70-80% Transobturator approach poorer outcome than retropubic Post hoc analysis of RCT comparing one surgical technique to another reported higher failure and more adverse effects for repeat surgery. No difference between the procedures. Repeat sling vs tightening of existing sling Pubo-vaginal slings AFS vs Colposuspension- no difference in efficacy
Previous >2 operations: cure rate- colposuspension 0%, AFS- 38% Amaye Obu etal 1998 ISD: spiral slings, adjustable slings Bulking agents: little data 65% primary, redo 35% AUS: case series-59-88%, mechanical failure 44%, explanation 5.9-15% Summary: Good urethra- burch, retro/trans slings, loose fascial slings, Bad urethra- tight fascial sling, bulkers, AUS
Selecting the correct tape What procedure to do? (pt condition, outcome data, Surgeon preference,sling options) TVT vs colposuspension ward and Hilton 2004 TVT vs porcine dermis Gurerrero et al 2010 TVT vs TVTO: similar efficacy Bladder injury, voiding problems, groin pain, vaginal injury Mini-sling vs MUS: meta analysis( Pain, reoperation) Latthe et al TVT vs mini arc: 3 year-inferior outcome Stefano Salvatore
ISD Re-do procedure: no RCT, retrospective studiesmixed message Age/Obesity: no difference in cure between TVT or TVTO Slings and POP: similar efficacy, voiding problems Mixed incontinence: UI improved by 42-100% Current trends: 50% TVTO, 15-20% mini, 30% retropubic
Meeting the challenge of obesity in pelvic floor surgery 5 unit increase in BMI= 20-70% increase risk of UI SUI OAB-bladder inflammation, urine production, mobility POP- development and progression of prolapse Conservative management: weight reduction, ISC Anesthetic risks, surgical risks (infection,surgical difficulty, TED), counseling SUI surgery outcome( meta-analysis 7): as safe as in nonobese, cure slightly lower 81% vs 85% POP surgery: same cure Wael, Agur