1. Overview of Stress Urinary Incontinence & Minimally Invasive Slings
Ken Maslow, M.D.
Urogynecology and Reconstructive Pelvic Surgery
Assistant Professor Department of Obstetrics & Gynecology
University of Manitoba

2. Etiologies of UI SUI – Stress UI UUI – Urge UI (OAB) Mixed UI
Functional UI (DIAPPERS)
Overflow UI
Other
Fistula, ectopic ureter, urethral diverticula
Uncategorised Incontinence
SUI- symp: leakage of urine on effort or exertion, or on sneezing & coughing
sign: observation of involuntary leakage from the urethra synchronously w exertional effort/cough/sneeze
Dx/condition: Urodynamic SUI=Genuine SUI- at CMG as involuntary leakage urine during increased abd pressure in the absence of a detrusor contraction.

3. ICS SUI Definitions Symptom Sign Diagnosis
Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing
Sign
Observation of involuntary leakage from the urethra, synchronous with exertion/effort, or sneezing or coughing
Diagnosis
Urodynamic SUI: involuntary leakage of urine during CMG with increased abdominal pressure, in the absence of a detrusor contraction
Sympt:ICS considers SUI to be unsatisfactory b/c of mental connotations: Effort incontinence preferred
Sign: must be synchronous as cough induced detrusor contraction
Urodynamic SUI=Genuine SUI

4. SUI: Mechanism Hypermobility (theory as to mechanism of SUI)
Hammock theory – pressure applied to anterior urethra it is compressed against well supported posterior urethra which occludes the lumen
Pressure transmission theory – with mobility the pressure transmitted to the urethra is less than to the bladder, can be measured with dynamic UPP as PTRs (pressure transmission ratio)= Δ Pure/Δ vesical
Intrinsic urethral function of: collagen, smooth muscle, venous endothelium, neuro
ISD: No Standard Definition for Dx (Diagnosis based on) Causes ISD:
1. Clinical severity of incontinence congenital
2. Positive supine empty stress test trauma
3. MUCP <20 cm H2O prev sergery (antiincontinence surgery, extensive pelvic)
4. Valsalva LPP <60 cm H2O post radiation
5. Endoscopic evaluation of bladder neck spinal cord disease
6. FIXED elevated position estrogen deficiency-luminal water tight seal dependant on
epithelium, submucosal vasculature & collagenous matrix
Assessment of bladder neck:
1. Clinical observation
2. Q tip test
3. Cystoscopy
4. Straining cystogram
5. Ultrasound
6. Video UDS

5. SUI Treatment Non surgical Behavorial Surgical Lose weight (Level 1)
Timed toileting/↓ intake (1a)
Treat constipation
Stop smoking (cough)
Avoiding high impact activities/heavy lifting
Kegels (Level 1)
± biofeedback
Non surgical
Pessary
(Level II-III)
Meds
Imipramine
Not very effective
Duloxetine
Not available
Surgical
w/t loss Level I: Subak 2005 J of Urology
Decreasing fluid intake Level I: Swithinbank 2005 J of Urology
Biofeedback – perineometer or vaginal electrical activity
Kegels sec squeeze, cont/3-4 x per day
(done correctly, Pt did better in intense program)
Non surgical
extra and intra urethral occluding devices
Pt needs to learn to insert
Irritation, discomfort
Bleeding
Infection
Migration
Imipramine (TCA)- α agonist & anticholinergic (25 mg po tid)
Duloxetine (SNRIs)-
potent inhibitor of the neuronal reuptake of serotonin and noradrenaline (SNRI)
an indirectly acting agonist of serotonin and noradrenaline receptors
serotonergic agonists generally suppress parasympathetic activity and enhance sympathetic and somatic activity
Specifically increase to sacral spinal cord (Onuf’s nucleus) which via peudendal nerve stimulates striated sphincter
Level 1 evidence (3-phase 3 trials) sign better than placebo for reduction in incont episodes
Estrogen: Cochrane Review 2003
Estrogen vs placebo
SUI subjective (46/107, 43% versus 29/109, 27%; RR 1.62, 95% CI: 1.15 to 2.28)
Meta-analysis 2003 Drutz
4 placebo controlled RCT
No sig. difference for SUI
WHI 2005
Placebo vs oral HRT RCT
Sig. worsening of symptoms of SUI in baseline symptomatic & asymptomatic women

6. Kegels / PFMT Level 1 evidence effective for SUI Tx
Ensure Pt contracting correct muscles
No one program recommended
3-5 sec squeeze, cont/3-5 x per day
Addition of biofeedback, vag cones, or electrical stimulation no benefit
However in Pt who do not isolate correct muscles, may be benefit of biofeedback devices
Pelvic floor physiotherapist
NB: incorrect pelvic floor muscle contractions can make the incontinence worse!
Pelvic tilt, gluteals, valsalva manuver most common mistakes

7. Vaginal Pessaries Intravaginal devices (Continence pessaries)
Support the bladder neck
Occlusive devices
External to meatus (Miniguard, FemAssist)
Ineffective & local irritation
Intraurethral (Femsoft)
Effective
Discomfort, UTI, hematuria, migration
Advantage
Instant symptom control
Non invasive
Reversible with no long term sequela (vs surgery)
Situational use (sports)
No major comp
Disadvantage
Fitting & refitting required
Maintenance
Problem with pessary:infection, erosion, etc

8. Surgical Tx SUI Anterior colporraphy Needle suspension procedures
Kelly plication suture
Needle suspension procedures
Stamey, Raz, Pereyra, Gittes
Retropubic urethropexy
Burch, MMK
Suburethral Sling procedures
Traditional Slings, Minimally invasive midurethral slings
Periurethral bulking procedures
Artificial Sphincter
Anterior repair & Needle suspension
Did not prove to be as efficacious

9. Burch Procedure Retropubic urethropexy
Significantly more effective than:
Pelvic floor muscle training
Anterior repair
Needle suspensions
Periurethral injections
Burch better than MMK
2 RCT’s: less failure RR 0.38, 95% CI
Equivilant to Sling as primary procedure
Burch controversial as repeat procedure or in ISD Pt

10. Midurethral Slings

11. Suprapubic Approach Variations/Surgical technique Traditional slings
New midurethral slings (TVT, TOT)
Differences b/t traditional vs new slings
amount of dissection
position – bl neck vs mid urethral
anchoring sites
tension

12. Obturator Approach Transobturator tape (TOT) Delorme 2001
To avoid retropubic space to decrease bladder, bowel, large vessel injuries
TVT vs TOT:
deTayrac R, Deffieux X, Droupy S, Chauveaud-Lambling A, Calvanese-Benamour L, Fernandez H A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. American Journal of Obstetrics & Gynecology. 190(3):602-8, 2004 Mar.
Equal efficacy at one year
Transobturator tape (TOT)

14. Midurethral Sling Day surgery 10-20 minute procedure
IV Sedation & local freezing
Requires 1-2 weeks off work
Complications Rare
Bleeding, infection, voiding dysfunction, mesh erosion, de novo/worsening UUI
TVT: bladder/bowel/lg vessel injury
TOT: vaginal perforation, leg/groin pain
Efficacy
90% cure at one year
Comparable to Burch at 2 yrs F/U (RCT: Ward 2004)
Small RCT’s comparing TVT to TOT with up to 1 year F/U

15. “Mini – Sling” TVT SECUR System ? Less groin pain ? Less anesthetic
?Less dissection/injury/bleeding

16. Urogynecology & Reconstructive Pelvic Surgery
Summary
SUI is a common problem in women
Conservative Tx
Kegels, weight reduction, pessary, (meds)
Surgical Tx
Minimally invasive mid urethral slings
Day surgery
Quick recovery
Little risk
Good outcome
Ken Maslow
Urogynecology & Reconstructive Pelvic Surgery
St. Boniface ACF
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