Case Presentation Ahmed S. El-Azab, MD Associate Professor of - - PowerPoint PPT Presentation

Case Presentation

Ahmed S. El-Azab, MD Associate Professor of Urology Section of Female Urology & NeuroUrology Asyut University Urology and Nephrology Hospital

Case # 1

 Ms. M. I., a 48 yr old ♀, teacher, menstruating. no

history of diabetes or other medical condition

 CC: Urine leakage on activities as sneezing, coughing,

episodes of urgency and UI, bothered

 P/E:

 Assess urethral support and mobility  Stress maneuver (cough Vs. Valsalva)  Assess pelvic organ prolapse.

• SUI obvious, stage I AVWP, ureth hypermobility

 What is Next?!

• Preop. Assessment

 Voiding diary  U/A  VCUG  Pad test  Q-tip test  Urodynamics

― Indications of Urodynamics in SUI

Q-tip ip test

Pad Test

 Length of the test:  Office Vs Home:  Pyridium:  Stress Vs. Rest:

Inter erpreta etatio ion

Cost Effectiveness of Urodynamics

1. Mixed incontinence, Significant urge component 2. Before surgery 3. Previous failed incontinence surgery 4. Known or suspected neurologic disease 5. History of urinary retention 6. High PVR 7. Elderly patient (ie, >65 y) 8. Pelvic organ prolapse 9. Diabetes (bladder neuropathy) 10. Nocturnal enuresis 11. Nulliparous woman with stress incontinence

Urodynamics

What operation?

 Mid-urethral sling; TVT vs TOT

 Same outcome!!  Prolene mesh vs. autologous midurethral sling  TOT easier to put but more difficult to remove  Pain after TOT:

 Obturator n. damage  rare as it is far from trocars  Irritation to bone (more common)

Bladder TVT Needles

Prolene Mesh Sling Pubic Symphysis

Picture courtesy of M. Walters

Surgery

 TOT  On 2nd postop day  What if she could not void? For how long you

keep on CIC before you institute urethrolysis?

— Immediate, 2 weeks, 4 weeks, 3 months

 On 2nd postop day catheter was removed and

trial of voiding …. She voided with only 50 mL PVR

 She was discharged home

Follow up

 1 month later:

— she reported No SUI, but complains of urgency and

few episodes of urge incontinence

—What is next?

Follow up

 1 month later:

— she reported No SUI, but complains of urgency and

few episodes of urge incontinence

—What is next? — Timed voiding — Behavioral modifications — Anticholinergics

Follow up

 6 month later:

— she reported No SUI, but still bothered by the

storage symptoms of urgency and urge incontinence. She reported that treatment did not work that much to improve her symptoms

— what is next?

Follow up

 1 month later:

— she reported No SUI, but complains of urgency and

few episodes of urge incontinence, still bothered

— Differential diagnosis:

Follow up

—What is next?

— History — P/E — PVR  85 mL — U/A  free — Voiding diary — Urodynamics — Cysto?

Qmax: 10 mL/sec Pdet@Qmax 64cmH2O

Question to the panel

 How would you diagnose bladder outlet

• bstruction in women?

— could be difficult, no definite criteria!! — Women may not be able to void at all for a

urodynamic study, and thus we do not have access to pressure flow data  Importance of the initial noninvasive uroflow

Asyut Experience

— Most accepted nomograms use PdetQmax ≥20–25

cmH2O

—Abnormal Qmax ≤11 - 15 ml/s —free flow is more representative!! —At our institute:

—PdetQmax >20 cm of water when the Qmax is ≤12 ml/s

• r

—PdetQmax >30 cm of water when the Qmax is 12-15

ml/s.

Urethrolysis

 This woman was scheduled for urethrolysis  Optimal time after sling insertion:

Expert Opinions

in Female Urology

• Prof. Hassan Abdelatif Abolella MD,

Professor of Urology, Assiut University .

Case Number (1)

OAB and small capacity:

 A 65 year – old, gravid 3, para3, Woman with history

• f overactive bladder (OAB) symptoms , present

with refractory OAB to 3 medications that did not

• work. She stopped all medications after 3 months

with no benefit. She describes her incontinence as mostly urge type .She had history of a motor car accident (MCA) and had local surgery for disc herniation for instability after MCA.

 She has had therapy with percutaneous tibial nerve

stimulation (PTNS) before her currently referral with no benefit after several sessions of PTNS.

 On examination:-

No stress incontinence with full bladder.- An attempt to fill her bladder with saline reveals that she can only tolerate a small amount of fluid of less than 65 ml.- PVR is 35 ml, and her urine analysis is negative . # How would you proceed with this patient ?

 This patient suffers from detrusor overactivity

incontinence with small bladder capacity and high pressure voiding and increased EMG activity during voiding.

 Firstly, a second filling cycle at slow filling rate,

instruct the patient to void without voluntarily contracting pelvic floor

 This patient wishes to avoid major surgery :

Augmentation cystoplasty or urinary diversion. # The first option is: Intradetrusor injection of 100U Onabotulinum toxin A. # The second option is Sacral neuromodulation.

ICI 2009 - 4th International Consultation on Incontinence

Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence

Case Number (2)

 Urethral diverticulum

A 27 year-old, gravid 3, para 3, woman presents with several years’ history of vaginal pain and voiding symptoms. Her lower urinary tract symptoms include difficulty, urgency, frequency and feeling of incomplete emptying. She has had culture documented infections every 2 months for at least the last 12 months.

She also describes a history of stress urinary incontinence

• ccurring at least 2-3 times a day.

She had a past history of 3 vaginal deliveries . Her physical examination revealed palpable suburethral mass extended proximally to the level of bladder neck. Her urinalysis is negative and post-void residual urine is 95 ml. How would you proceed with her therapy ?

Culture specific antibiotic therapy. # An inverted U –shaped incision. Incise the periurethral fascia transversely to raise proximal and distal flaps. Dissection and excision of the diverticulum. Harvest the autologous fascia and perforate the endopelvic fascia lateral to the periurethral fascia. Longitudinal closure of the urethral defect over urethral catheter, transverse closure of periurethral fascia. Midurethral sling fixed without tension to the rectus

• sheath. Foly catheter is left indwelling for10-14 days.

# synthetic sling is contraindicated.

Case Number (3) Stress incontinence and intrinsic sphincter deficiency

 A 59 – year- old, gravid 4, para 3, active woman

presents for management of symptomatic and fairly severe urinary incontinence.

 She wears about 7 pads a day for protection and has

tried anticholinergics with no improvement. She describes mainly stress incontinence and no overt urge symptoms although she states she leaks all the time when standing or walking.

She has no nocturnal leakage. Her past history is significant for some vaginal atrophy and a pervious abdominal hystrectomy for benign disease at which time she had a mini-sling performed for urinary incontinence. Her examination demonstrates easy stress incontinence (urethral mobility 20-30 degrees). She has no prolapse. How would you proceed ? Do you think she needs to have her sling incised / cut if one is performing another sling ? if so, what type of sling ? What would you recommened ?

# Minority of patients with SUI would be classified as

predominantly having ISD (10-15%). # Most patients presenting with SUI due to moderate or severe ISD ,defined for discussion purposes as an abdominal leak point pressure ( ALPP ) less than 100 cm at low bladder filling volumes with or without further decreasing ALPP with increasing bladder volume testing. # Mid urethral retropubic sling procedures allow passive extrinsic compression of the urethra to induce increased circumferential urethral resistance without any degree of tension applied to the sling arms at the time of fixation .

Pathophysiology of Stress Urinary Incontinence

• Urethral Hypermobility

– Displacement of urethra during sudden increase in abdominal pressure – Decreases pressure transmission

Pathophysiology of Stress Urinary Incontinence

• Intrinsic Sphincter

Deficiency (ISD) – Urethra is unable to generate enough

• utlet resistance to

keep the urethra closed at rest or with minimal physical activity

Normal Closure Abnormal Closure

SUI Occurs When;

Bladder Pressure > Urethral Pressure

• Any factor that pushes

the equation towards a positive urethral pressure gradient has the potential to be effective

Surgery Exercises, medication Cough control, weight loss

.

Case Number (4) Sling perforation into urethra

A 43 year-old woman is referred for recurrent urinary tract infection (UTIs) and dysuria after a transobturator midurethral synthetic sling (TOT) . The sling was perfomed 5 months ago for pure stress urinary incontinence (SUI). Since then she has had four attacks of UTIs. After treatment the dysuria subsides but never fully

• resolves. Prior to the sling she had one UTI 25 years ago.

The patient’s voided urine has many epithelial cells and you decide to pass a catheter to obtain a better urine sample . As the catheter is first inserted you feel some roughness and the patient shrieks in pain. She has mild tenderness over the midurethra but no mesh exposure. She has no prolapse. Post void residual urine by US was 40 ml. Cystourethroscopy is performed. The bladder appears

• normal. There is synthetic mesh in her mid-to distal

urethra. How would you proceed ?

# Low dose antimicrobial suppressive therapy to reduce her risk of another UTI. # Urine culture 1 week before surgery.

# An inverted U –shaped anterior vaginal wall incision to

excise the portion of sling which had eroded into the urethra as well as the lateral portions of the sling up to the level of endopelvic fascia. Closure of urethral mucosal defect ,reapproximation of periurethral fascia over the urethra. Martius labial fat pad graft over the repair. A Foley catheter

for 7-10 days. Pull –out cystourethrogram before catheter removal. # Autologous rectus fascia pubovaginal sling at the time of mesh removal .

CASE 5

63 yr old female teacher

 Extreme urgency and frequency for 3 years,

never incontinent

 Come with diagnosis of “ interstitial cystitis”

• C/O severe knife like pain with urination
• Urine +ve RBC,
• PSH:TOT 5 yrs ago for SUI
• PMH: DH, HTN
• Exam: negative pelvic exam

What would be your next step??

Next step

 Psycological Evaluation  Vaginal Ultrasound  Urodynamics  Cytology  Cystoscopy  Send to distant center for evaluaton

Answer

 Urine cytology is frequently negative, but a negative result on

urine cytology is not sufficient to rule out malignant tumor.

 Cystoscopy is generally indicated in patients with complicated

OAB who have undergone prior pelvic or anti-incontinence surgery or are suspected of having underlying anatomic pathology by the nature of their initial assessment (ie, hematuria, recurrent infection).

 Cystoscopy is a must, moreover, complication resulting from

TOT such as urethral fistula or erosion should be ruled out

Cystoscopy: tape appear to be in the bladder on the left side

 I thought this was impossible: “it is a TOT”

Resident comment

 How frequent ??  Possible to miss by scope !  How to remove it ??

Case Number (6)

Post – cystectomy prolapse

 A 55-year-old woman presents with prolapse having

undergone a radical cystectomy and orthotopic w- neobladder for transitional cell carcinoma (TCC) of the urinary bladder 1 year ago.

 Her pathology revealed a muscle invasive TCC and her

lymph nodes were negative. Of note is that her vagina was partially resected (anterior wall) along with her uterus ,tubes and ovaries (anterior exenteration).

 Her prolapse has developed over the last 6 months

and is affecting her quality of life .She has difficulty in walking, friction, spotting and excoriation.

 On examination: -

An obvious stage IV prolapse and her total vaginal length is 6-7 cm on maximal stretch / push.

 She would, ideally, like to be sexually active.

# How would you proceed with counseling her about

• ptions?

This is very difficult and challenging case. Surgical options include abdominal and transvaginal approaches. # Colpocleisis :is not an option for her as she is keen to remain sexually active.

# Sacrocolpopexy (abdominal or lap.):surgeon

needs to be aware of the position of the neobladder and ureters.

# Transvaginal sacrospinous ligament mesh

fixation and sutures secured it distally to the under surface

• f pubic symphysis and close the gap between lateral

mesh edge and pelvic sidewall with interrupted sutures.