Date post: | 02-Dec-2014 |
Category: |
Health & Medicine |
Upload: | aboubakr-mohamed-elnashar |
View: | 239 times |
Download: | 3 times |
Benha University Hospital, Egypt Aboubakr Elnashar
•By placing a prolene tape around the
midurethera without tension Restores
the pubourethral ligaments & the
suburetheral vaginal wall Dynamic
kinking of the midurthera at stress (Rezapour et al, 2001)
•Corrects the central & lateral fascial
defects of the anterior compartment of the
vagina (Ursula et al,2000) Aboubakr Elnashar
1.Anticoagulant therapy (stop 14 d or
replace with low dose heparin)
2.Urinary tract infection
3.No sexual intercourse, heavy
lifting or exercise for 1mo
Aboubakr Elnashar
1.Genuine SI.
2.SI with Intrinsic sphincter deficiency (urethral p <20 cm H2O).
3.Mixed I (urge & stress).
4.Recurrent SI (previous traditional
surgical procedure had failed).
Aboubakr Elnashar
1. Pregnancy
2. Women with plan for future pregnancy (prolene
mesh will not stretch significantly).
Incontinence may recur.
3. Motor urge incontinence & significant detrusor
instability (Ulmsten,2001)
Aboubakr Elnashar
• Ursula et al,2000: 8.7% in 1762 patients
1. Bladder perforation: 5.4%. The most frequent
complication
2. De novo urgency or urge incontinence: 5.1%
3. Retropubic haematoma: 0.8%
4. Rare complications
a. Anterior vaginal wall laceration
b. Retained plastic sheath
c. Obturator nerve irritation
d. Vaginal wound infection Aboubakr Elnashar
• Cochrane library, 2002: 682 women
•1 in 11 had a complication during TVT,
•Most commonly bladder perforation
•None had serious consequences
Aboubakr Elnashar
Ursula et al(2000) 1762 patients
Objective improvement: (Cough stress
test, pad test, urodynamics)
87.3%
Subjective improvement:
89.3%
Aboubakr Elnashar
4 different groups of patients:
GSI, Recurrent, ISD, Mixed
Cure: Pad test < 10 g of urine/24 h,
Quality of life improved > 90%
Improvement:Pad test <15 g of urine/24 h,
Quality of life improvement >75%
Aboubakr Elnashar
1.Genuine SI
Nilsson et al, 2001:85 patients, follow-up 5 yrs
• Retropubic hematoma: 3.3%
Bladder perforation: 1.1%
Intraoperative bleeding >200ml: 3.3%
Postoperative voiding difficulties: 4.4%
UTI: 7.8%
Infection of operating site: 1.1%
Aboubakr Elnashar
•Complete cure (no leak at all & no voiding problems): 84.6%
Significant improvement (leak occasionally): 10.6%
No significant decline in efficacy over an extended period
Failure rate: 4.8%
• De novo urge symptoms: 5.9%
Aboubakr Elnashar
2.Recurrent SI
Rezapour & Ulmsten, 2000: 34 patients, Follow up for 5
yrs
• No significant intra-or postoperative complications
Bladder perforation: 1 patient
Post operative urinary retention: higher than that of
uncomplicated SI
• Cure rate: 82%
Significant improvement: 9%
Failure: 9%
• No long term complications
Aboubakr Elnashar
3.SI with ISD (hypotonic urethera, Type 3
incontinence)
Difficult to cure
Rezapour et al,2001: 49 women, follow-up 4 yrs
• Bladder perforation: 1 patient
Small hematoma: 11%
Temporary postoperative voiding problems: 23%
Aboubakr Elnashar
• Complete cure: 74% (equal or better
than traditional surgery)
Significant improvement: 12%
Failure: 14% (more than that in genuine
SI). The majority in >70 yrs, urethral p
<10 cm H2O & immobile urethra.
• No LT complications, No LT urinary
retention
Aboubakr Elnashar
4.Mixed ( urge & stress)
Rezapour & Ulmsten, 2001: 80 women, follow-up 4 yrs
Urge component may consist of:
1.detrusor instability with low bladder volume <200 ml (excluded & treated with anticholinergics),
2.uretheral relaxation or
3.uninhibited premature micturition reflex
• Postoperative voiding problems: 18%
Bladder perforation: 1 patient
Small heamatoma: 8% & Significant haematoma: 1patient (on anticoagulant)
Aboubakr Elnashar
• Cure rate: 85%
Improvement: 4%
Failure: 11%
Urgency without incontinence: 25% of the cured & improved women
Aboubakr Elnashar
Provided that a urodynamic evaluation is done, TVT can be used in mixed I.
Not only the stress but also the urge I was cured or improved in 85%. ?
TVT:
1. Minimal vaginal dissection, the tape is placed tension-free around the mid urethra. So, the proximal part of the urethra & bladder neck which are densely innervated would be less compromised than in other sling operations
2.Causes only dynamic Kinking of the midurethera at stress & less likely to obstruct urine flow at micturition
Aboubakr Elnashar
•Cochrane library, 2002: 682 women
•Cure rates after TVT were similar to those
following open abdominal retropubic
suspension.
•No difference in: voiding dysfunction,
urge incontinence or
detrusor instability between
suburetheral slings & abdominal or needle suspensions Aboubakr Elnashar
•Ursula et al,2000
Contrary to Burch colposuspension in which a
continuous decline of success, no such
deterioration has been reported with TVT
TVT creates a new hammock under the
midurethera. The tape is invaded by fibroblast
during the course of time, thereby stabilizing its
position with time
Aboubakr Elnashar
1. TVT cannot be expected to treat all types of
incontinence
2. TVT is effective, safe & long lasting, also in
previous operated patients
3. TVT can be used in ISD SUI, even with low
cure rate compared to GSI
Aboubakr Elnashar
4. TVT can be used in MSI to cure or
improve also urge symptoms
5. TVT results are comparable to traditional
surgery but simple & less invasive
6. TVT cure rate is about 90% lasting for 5
yrs, with few intra & postoperative
complications
Aboubakr Elnashar