1. Intrinsic Sphincter Deficiency & Slings
Nader Gad
MBChB, MChGO, FRCOG, FRANZCOG
Consultant & Senior Lecturer in O&G
Royal Darwin Hospital, Darwin, Australia

2. Definition of ISD SLPP less than 60 cmH2O MUCP less than 20 cmH2O
Type III Stress Incontinence (Proximal urethra open at rest)

3. Classification of SUI Clinically & During UDA
Bladder neck & proximal urethra
During Rest
Bladder Neck & Proximal urethra
During Stress
Cystocele
Type 0
No SUI is seen
Probably due to momentary voluntary contraction of
External Urethral sphincter
closed at rest
At or above inferior Margin of SP
Descend & open
None
Type I
Closed at rest
Above inferior Margin of SP
Open
Descend less than 2 cm
None or Small Cystocele
Type IIA
Rotational descent characteristic of cysto-uretherocele
Present
Type IIB
Closed
At or below inferior Margin of SP
May be further descent
Type III
Open at rest
Proximal urethra no longer function as sphincter

4. Causes Of ISD Previous Pelvic Surgery Anti-incontinence surgery
Urethral diverticulectomy
Radical Hysterectomy
Urethrotomy
Resection or incision of vesical neck
Aging & Hypo-oestrogenic States
Pelvic Irradiation
Neurologic Conditions
Myelodysplasia
Anterior spinal artery syndtome
Lumbosacral neurologic conditions
Shy-Drager syndrome

5. Treatment of ISD
McGuire et al(1978 )were the first to note that ISD present in :
75% of women of patients who failed in multiple surgeries for SUI
13% with no previous anticontinence surgery
Difficult to determine is it cause or effect?

6. Treatment of ISD Sand et al (1987):
High failure rate of Burch colposuspension in women with low MUCP compared to those with MUCP more than 20cm H2O
Failure rate of Burch at 3 months FU:
Low MUCP: 54%
Normal MUCP: 18%

7. Treatment of ISD
Most data show simple elevation of the bladder neck is ineffective
Recommend more obstructive procedure

8. Treatment of ISD Proximal Suburethral slings (Traditional)
Mid-Urethral Tension-free Slings:
TVT
TOT
3. Artificial sphincter
4. Urethral Bulking Procedures

9. Proximal Suburethral Slings
First introduced by Giordano in 1907 using Gracilis muscle flap
Aldridge in 1942, developed the Fascial sling
The principle:
Create a hammock underneath bladder neck to prevent descent and provide a backboard at UVJ against which the urethra is compressed during increase of intra-abdominal pressure

10. Types of Proximal Slings
Biologic
Synthetic
Fascia lata
Mersilene
Rectus fascia
Nylon
Gracilis muscle flap
Marlex
Pyramidalis muscle flap
Gore-tex
Round ligament
Silastic
Ox dura mater
Polypropylene mesh
Porcine small intestine submucosa
Cadaver fascia

11. Patient most un-suitable
History of irradiation
Previous sling erosion
Having surgery on the urethra at the same time (e.g., urethral diverticulectomy)
Having POP surgery at the same time

12. Proximal Urethral slings
Overall success for SUI + ISD at 5 years = 80 – 90%
Summitt et al (1990)
Sling procedure success rates were:
93% in ISD + HMBN
20% in ISD + no HMBN

13. Common Complications of Proximal Suburethral Slings
Longer recovery
Has the highest rate of retention: 2-37%

14. TVT & ISD Rezapour (2001) First report on 49 women: F-U for 3-5 years:
74% completely cured
12% improved
14% no improvement:
Majority more than 70 years old & MUCP less than 10 cmH2O

15. TVT & ISD Overall Success rate: 55 – 74%
(less than the 80-90% with PSUS)
Some experts advise when TVT in ISD:
tape is placed in immediate proximity with urethra (still without tension) instead of aiming for a ¼ inch gap

16. TVT Complications Voiding difficulties Recurrent UTI
Bladder perforation (5-10%)
Erosion (3 – 5 %)
Vascular injury
Bowel injury
Haematoma
Nerve injury
Death (6 reported deaths by September of 2002)

17. TOT & Slings
It leaves the sling in a more horizontal or hammock-like rather than U-orientation
Less operative time
Avoid risk of injury to bladder (only few reported cases) bowel & major vessels

18. TVT vs TOT (Monarc) Miller et al (2006)
Retrospective study of 145 women Comparing TOT (Monarc) vs TVT under GA or Spinal anaesthesia :
Monarc was nearly 6 times more likely to fail at 3 months after surgery in women with borderline MUCP (42 cm H2O or less)
In this study women with MUCP 20cmH2O or less
were exclusion criteria of TOT but not TVT

19. Failure Rate TVT vs TOT Miller et al 2006
Monarc (85)
All (145) Objective
Subjective 3%
14% 9%
16%
MUCP 42 or less (81) Objective
13%
23%
MUCP more than 42 (64) Objective 4% 2% 6%

20. TVT vs TOT vs Sling Jeon et al (2008)
Retrospective study of 253 women with ISD defined as: LPP less than 60 cmH2O or MUCP less than 20 cmH2O
- PVS: 87
TVT: 94
TOT: 72
TOT (polypropylene; Iris, Dowmedics Co, Korea, Outside – in )
Regional of General Anaesthesia

21. TVT vs TOT vs Sling Jeon et al (2008)
Cure rates after 2 years:
PVS: 87%
TVT: 87%
TOT: 35 %
Cure rate after 7 years:
PVS: 59%
TVT: 55%

22. TVT vs TOT vs Sling Jeon et al (2008)
Complications
PVS (n=87)
TVT (n=94)
TOT (n=72)
P value
Bladder injury
1 (1.2%)
0.6
De novo urgency
14 (16%)
14 (15%)
13 (18%)
0.9
Voiding dysfunction
(one month or longer)
18 (19%)
17 (18%)
8 (11%)
0.75
V.D. Requiring surgery
3 (3.1%)
1 (1.4%)
0.26
Recurrent UTI
2 (2.3%)
6 (6.4%)
0.06
Mesh Erosion -
1 (1.1%) 1

23. Darwin Experience
Retrospective study of my First 25 cases of the TVT-O procedures (J&J)
Procedure were completed in all women under sedation and local anaesthesia
Outcome of the procedure:
Complication: intra- & post-operative
Success rate: Subjective & Cough test
Any difference in outcome when ISD present?

24. Darwin Experience
ISD was defined as valsalva or cough LPP = less than 60 cmH2O and/or MUCP = 20 cm H2O or less
Women with ISD were given the option to chose between TVT vs TVT-O:
TVT have a higher cure rate than TVT-O in women with ISD
TVT has the potential risk of bowel or major blood vessels injury

25. Previous surgery for SUI Previous Hysterectomy
Patients studied
Public 7
28%
Private 18
72%
GP referral 20
80%
Specialist Ref 5
20%
Age
39 – 66 years
Parity
1 – 6
Presence of SUI
In All women
100%
Urgency
9/25
36%
Urge incontinence
5/25
Frequency
6/25
24%
Nocturia
Previous surgery for SUI
3/25
12%
Previous Hysterectomy
10/25
40%
Previous POP repair

26. UDA Findings Presence of POP 15/25 60% HMBN 21/25 84% ISD 10/25 40%
6/25
24%
ISD alone
4/25
16% DI
2/25 8%

27. ISD Of the ten women with diagnosis of ISD:
a. 5 women (50%) had MUCP < 20cm H2O
4 women had leakage on valsalva
the remaining patient had leakage on Cough LPP of less than 60 cm H2O, this patient was the only patient lost to follow up.

28. Sedation Bolus of 1-2 mg midazolam
Then propofol 1% infusion at a rate of 20-40mls/hour titrated to effect
A small bolus of propofol (10-30mg) and/or alfentanil (100 – 200mcg) may be used when required in some patients during penetration of Obturator membranes.

29. Local Anaesthesia
The local anaesthetic agent used was a total of 80 – 100 ml of 0.25% prilocaine with adrenaline (1:200,000)

30. Local Anaesthesia Administration of local anaesthesia to:
the area of the suburethral vaginal incision
paraurethral lateral dissection
expected tape passage through the Obturator foramen and muscles and the exit on the skin of the inner upper part of the thigh on both sides.

31. Cough Test Once tape is inserted, cessation of all sedation
Bladder is filled to a volume similar to that when SUI was demonstrated during UDA
Cystoscopy performed
When patient is awake enough, operative table is tilted head up about 30 degrees
patient is instructed to cough strongly and the tape is very slowly adjusted to the point when urinary leakage just stops

32. Operative & Short-term Complications
Intra-operative complications 0%
Short term Urinary retention
Short Term DI
1/25 4%
One woman had 2 episode of nocturnal enuresis on the 2nd and 7th postoperative and day that resolved by the time she was reviewed 5 weeks later
Short term postoperative complications
2/25 8%
2 patients (8%) developed significant pain in the upper thigh that resolved by 6 weeks post surgery

33. Hospital Stay AM list 7 28% 6/7 86% PM List 18 72% 2/18 11% 14/18 78%
Discharge of AM list on same day
6/7
86%
PM List 18
72%
Discharged on the same day
2/18
11%
Discharged next morning
14/18
78%
Discharged within 48 hours

34. Follow-up Duration of FU Duration to Audit Mean = 4 – 52 weeks
Average = 13.3 weeks
Duration to Audit
Mean = 7 – 156 weeks
Average = 53 weeks

35. Long Term Outcome Urinary retention 0% Urgency 2 8%0%
Urgency 2 8%
Two woman developed mild urgency
Other complications 1 4%
Pain in the vagina required excision of part of the tape
No further SUI
24/24
100%

36. August 2008 Anast et al from Missouri, USA
TOS (Trans-Obturator Sling) placement a outside-in (ObTape –Coloplast Surgical, Humeleback, Denmark)
124 patients had leakage on valsalva:
29% had low VLPP (Less than 60 cmH2O)
71% had higher VLPP

37. August 2008 Anast et al, Missouri, USA
At a mean of 12 month
Low VLPP (29%)
High VLPP (71%)
Subjective Cure rate
93%
79%
Bladder perforation
(6 patients) 3% 6%
Complication rate
11%
29%

38. Conclusion
TVT-O under local anaesthesia and sedation with the Cough Test in Theatre is very effective and safe surgical treatment of SUI in women with or without ISD.
Shortcomings of the Study:
Retrospective
Small number of the patient in this study
Relatively short term follow up period