Decision making with the USI patient Neuman Menahem 13 th Turkish Ob/Gyn Annual meeting Antalya Disclosure: Menahem Neuman is consultant for Serag-Wiessner. Urogynecology Service, Western Galilee MC, Nahariya, the Faculty of medicine, Bar-Ilan University, Safed, Israel.

Decision making with the USI patient Diagnosis Pre treatment consultation Surgery Complication Failure Follow-up Menahem Neuman

Decision making with the USI patient Diagnosis Pre treatment consultation Surgery Complication Failure Follow-up Menahem Neuman

Diagnosis History taking, pelvic exam. Cystoscopy? US? Cytology? Urodynamics? Menahem Neuman

Decision making with the USI patient Urodynamics? Curr Opin Obstet Gynecol , van Leijsen Preoperative urodynamics do not improve outcome in women with complaints of stress incontinence The routine use in women with uncomplicated stress incontinence should no longer be advised. Preoperative urodynamic evaluation should only be used to answer a specific clinical question Menahem Neuman

Decision making with the USI patient Urodynamics in Korea? Korean J Urol – 2014, Agarwal A Statistically significantly better treatment outcomes in the urodynamic group Menahem Neuman

Decision making with the USI patient Rachaneni, Latthe: BJOG A systematic review and meta-analysis. Urodynamics does not improve outcomes With careful office evaluation! Menahem Neuman

Decision making with the USI patient Meschia, Cardozo, Int Urogynecol J 2015 The role of urodynamic studies before prolapse surgery is a hotly debated. There is no evidence that the outcome of surgery is altered by prior UDS. Menahem Neuman

Decision making with the USI patient USI USI predominance Combined Others Menahem Neuman

Decision making with the USI patient USI USI predominance Combined Others Menahem Neuman

Decision making with the USI patient Diagnosis Pre treatment consultation Surgery Complication Failure Follow-up Menahem Neuman

Consultation Medical? Physiotherapy? Surgery! Menahem Neuman

Decision making with the USI patient Physiotherapy? Menahem Neuman Berghmans, N Engl J Med Surgery, as compared with physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year.

Decision making with the USI patient Diagnosis Pre treatment consultation Surgery Complication Failure Follow-up Menahem Neuman

Surgery Injectable? RP Open Colpo-Suspension? TVT Menahem Neuman

Surgery Injectable? RP Open Colpo-Suspension? TVT SMUS? SMUS-RP? SMUS-TOT? Mini SMUS? Menahem Neuman

The Mid-Urethra Concept Pubo-urethral ligaments Zacharin 1968, DeLancey 1994

Menahem Neuman The Mid-Urethra Concept Functional Aspects Maximal urethral closure pressure at mid-urethra Ulmsten 1976

Menahem Neuman Ulf Ulmsten - TVT Classic Over 1000 papers 6% Bladder penetration 5% P/O BOO Intestinal / vessel injuries

TVT Menahem Neuman

Over 150 papers 3% of P/O BOO Thigh pain – 30% Bladder & Urethral injuries, Field infection, Bleeding SUI treatment evolvement: TVT-O

Menahem Neuman

Is TVT better than TVT-O? Novara et al. Eur Urol, 2010 Menahem Neuman

Is outside-in better? Mahduvrata et al. Eur J Obstet Gynecol Reprod Biol, 2012 Menahem Neuman

Decision making with the USI patient SIMUS (Mini-Slings)? Menahem Neuman

Are mini slings better? Abdel-Fattah et al. Eur Urol, 2011

Eran Schreter and Menahem Neuman 7 years after anti-incontinence mini Mid-Urethral Sling (MUS) procedure: Patient’s own perspective and follow-up data Turkish-Israeli Urogyne MeetingJerusalem

33% had recurrence of rUSI, mostly after 5 years. 7 years after mini MUS

Decision making with the USI patient Menahem Neuman TVT for USI with ISD Minerva Chir. 2014, Kokanalı TVT is effective (83%) and safe for USI with ISD. However, ISD patients with low maximal urethral closure pressure should be informed preoperatively about possible poor outcomes

Decision making with the USI patient Menahem Neuman TVT for USI with ISD Int Urogynecol J. 2012, Choo With our long-term results, TVT is an effective treatment even in women with ISD (82%). ISD patients with low VLPP should be counseled carefully about TVT outcome

Decision making with the USI patient Menahem Neuman Management of recurrent stress urinary incontinence after failed MUS: a survey of members of the IUGA Int Urogynecol J. 2015, Robinson D, Cardozo L Members of IUGA prefer RPS in most patients and UBA with absent urethral hypermobility and ISD

Decision making with the USI patient Menahem Neuman Management of recurrent stress urinary incontinence in the US Neurourol Urodyn. 2015, Zimmern 6% of women with rUSI were retreated within 5 years, mostly with injection therapy or autologous fascial sling

Decision making with the USI patient Menahem Neuman The surgical management of rUSI: a systematic review Acta Obstet Gynecol Scand. 2015, Nikolopoulos There is a wide spectrum of surgical interventions for secondary treatment of SUI. A common characteristic is a lower success rate compared with those reported following primary procedures.

Decision making with the USI patient Menahem Neuman Surgical treatment of rUSI: a systematic review and meta-analysis of RCT’s Eur Urol. 2013, Abdel-Fattah No difference in patient-reported and objective cure rates between RP-TVT and TO-TVT in the surgical treatment of women with R-SUI.

Decision making with the USI patient Menahem Neuman Results of primary versus recurrent surgery to treat stress urinary incontinence in women Int Urogynecol J. 2015, Heesakkers Recurrent surgery to treat rSUI are do not differ from results of primary surgery.

Menahem Neuman Post TOT Thigh pain

Menahem Neuman Post TOT Thigh pain

Menahem Neuman Post TOT Thigh pain

Menahem Neuman Post TOT Thigh pain

Menahem Neuman Post TOT Thigh pain

Gilad Reut and Neuman Menahem Menahem Neuman Turkish-Israeli Urogyne Jerusalem Meeting

 Needle trajectory medially remote according with FF (IUJ 2012)  A Trans - Obturator sub mid urethral short sling implant (12 Cm, TVT-Abbrevo, J&J)

102 Pts were included:  Early P/O thigh pain: 6 Pts (6%), all mild.  At 3 Yrs:  Chronic pain: 5 Pts – all mild  OAB : 11Pts (13%)  POP: 9 Pts (11%), mild  SUI: 2 Pts (2.5%), mild Menahem Neuman

Decision making with the USI patient Menahem Neuman Vaginal delivery following TVTS J Obstet Gynaecol Res. 2013, Tommaselli The patient remained continent throughout the gestation and in the following 24 months

Decision making with the USI patient Menahem Neuman Effect of pregnancy and delivery on urinary incontinence after the smus Int Urogynecol J. 2015, Cavkaytar Four patients had a TVT and 8 had TOT. Seven women had CS and 5 women VD. 10 were continent after delivery (83.3 %).

Decision making with the USI patient Concomitant surgical correction of USI and anterior vaginal wall prolapse Zargham, J Res Med Sci – 2013 Anterior vaginal wall reconstruction can improve SUI surgery outcome at 18 months Menahem Neuman

Decision making with the USI patient Menahem Neuman Pelvic organ prolapse in a cohort of women treated for stress urinary incontinence Am J Obstet Gynecol. 2014, Brubaker Surgeons may counsel women with asymptomatic stage 2 POP that their prolapse is unlikely to require surgery in the next 5-7 years

Decision making with the USI patient Menahem Neuman A SMUS to reduce SUI after vaginal prolapse repair N Engl J Med. 2012, Nygaard A prophylactic SMUS inserted during vaginal prolapse surgery resulted in a lower rate of USI but higher rates of adverse events

Decision making with the USI patient Menahem Neuman Prolapse surgery with or without USI surgery : a systematic review and meta-analysis of RCT’s BJOG 2014, Roovers Combination surgery reduces the risk of P/O USI, but adverse events were more frequent

Decision making with the USI patient Menahem Neuman Trans-vaginal prolapse repair with or without the addition of a SMUS: a randomized trial BJOG 2015, Roovers Women with prolapse and co-existing SUI are less likely to have SUI after trans-vaginal prolapse repair. Only 17% of the women undergoing POP surgery needed additional MUS

Decision making with the USI patient Menahem Neuman Sexual function in women before and after TVT Acta Obstet Gynecol Scand. 2014, Glavind Most women experience an improvement in sexual life after a TVT mainly because of absence of incontinence during sexual activity or absence of fear of incontinence during sexual activity

Decision making with the USI patient Menahem Neuman Impact of incontinence surgery on sexual function: a systematic review J Sex Med. 2012, Jha Coital incontinence is significantly reduced following continence surgery

Decision making with the USI patient Menahem Neuman Autologous adipose stem cells in treatment of female stress urinary incontinence Stem Cells Transl Med. 2014, Nieminen The feasibility and efficacy of the treatment were not optimal

Decision making with the USI patient Menahem Neuman Robotic Burch colpo-suspension Int Urogynecol J Francis Robotic Burch colpo-suspension can be completed in a safe and effective Why?

Decision making with the USI patient Menahem Neuman Low-cost TVTO for the treatment of USI using ordinary polypropylene mesh Int Urogynecol J ElShenoufy Safe with 91% 5-year cure. It should be considered as a low-cost alternative to available commercial kits, mainly for public health systems with few financial resources

Decision making with the USI patient Menahem Neuman Surgeon-tailored polypropylene mesh Vs TVT-O Int Urol Nephrol Apr 22. Hassan Outcome of STM is comparable to TVT-O. Furthermore, STM is more economic Decision making with the USI patient

Menahem Neuman My own choice of Anti-incontinence operations: TOT, inside out TVT-RP for rUSI & ISD SIMUS (Mini sling) when vaginal wall tissue is poor Para urethral injectables – for the very friable Pts

Menahem Neuman