1. 排尿障礙治療中心 版權所有 Surgical Treatment of Stress Urinary Incontinence Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. 排尿障礙治療中心 版權所有 Surgical Goals for Stress Urinary Incontinence To restore urinary continence To preserve normal micturition Free of bladder outlet obstruction Not to create newly developed urge incontinence or exacerbate existing urge incontinence Not to jeopardize renal function

3. 排尿障礙治療中心 版權所有 Historical surgical procedures for stress urinary incontinence Kelly plication procedure Marshall-Marchetti-Kratz procedure Pereyra procedure Stamey bladder neck suspension Raz bladder neck suspension Gittes bladder neck suspension

4. 排尿障礙治療中心 版權所有 Marshall Marchetti Krantz Procedure

5. 排尿障礙治療中心 版權所有 Repair of Paravaginal defect

6. 排尿障礙治療中心 版權所有 Current popular surgical procedures for SUI Burch colposuspension procedure Fascial pubovaginal sling procedure Vaginal sling procedure Collagen, Teflon, fat injection Synthetic pubovaginal sling procedure Tension free vaginal tape Laparoscopic bladder neck suspension

7. 排尿障礙治療中心 版權所有 Burch colposuspension

8. 排尿障礙治療中心 版權所有 Periurethral injection for SUI

9. 排尿障礙治療中心 版權所有 Laparoscopic Bladder neck suspension

10. 排尿障礙治療中心 版權所有 Laparoscopic Colposuspension

11. 排尿障礙治療中心 版權所有 Long term (5-year) results of Anti-incontinence surgery n (a)Gittes BNS (n=62) (b) Raz BNS (n=53) (c)Pubovagina l sling(n=42) Statistics n%n%n% Dry602540.31222.62354.8(a)vs.(b)p<0.05 Improved612032.32547.21638.1(b)vs.(c)p<0.05 Success rate4572.63769.83992.9(a)vs.(c)p<0.05 Moderate SUI211117.7817.024.8(b)vs.(c)p<0.05 Severe SUI1569.7815.112.3

12. 排尿障礙治療中心 版權所有 Surgical results by Types of stress incontinence n (a)Type I SUI (n=12) (b)Type Ⅱ SUI (n=111) (c)Type Ⅲ SUI (n=34) Statistics n%n%n% Dry60650.04036.01441.2nonsignificant Improved61433.34843.2926.5 Success rate1083.38879.22367.7 nonsignificant Moderate SUI21216.71311.7722.6 Severe SUI150109.0619.4

13. 排尿障礙治療中心 版權所有 Success rates of SUI in Different surgical procedures n (a)Gittes BNS (n=62) n (b)Raz BNS (n=53) (b)Pubovaginal sling(n=42) Statistics n%n%n% Type I SUI128/1080.02/2100.0 Type II SUI11132/4178.033/4770.223/23100.0nonsignificant Type III SUI345/1145.52/450.016/1984.2(a)vs.(c)P<0.05 (b)vs.(c)P<0.05

14. 排尿障礙治療中心 版權所有 Goals for Surgical correction of Stress incontinence Adequate vaginal support of the urethra and bladder neck for urethral hypermobility Restoration of hammock effect during stress for damages in attachments to fascia pelvis Increase urethral coaptation if intrinsic sphincteric deficiency exists Correct prolapse concomitantly Do not create bladder outlet obstruction

15. 排尿障礙治療中心 版權所有 Elevated bladder neck after Incontinence surgery

16. 排尿障礙治療中心 版權所有 Defects in vaginal attachment and vaginal wall weakness

17. 排尿障礙治療中心 版權所有 Anterior colporrhaphy with pubovaginal sling procedure

18. 排尿障礙治療中心 版權所有 Pubovaginal Sling procedures Fascial sling – rectus fascia, fascia lata Sling on a string Artificial sling - mersilene silastic dacron marlex Cadaveric or porcine collagen sling Bone anchor sling TVT / SPARC – polypropylene mesh

19. 排尿障礙治療中心 版權所有 Techniques of Pubovaginal sling procedure

20. 排尿障礙治療中心 版權所有 Fascial and Silastic slings Silastic and fascial slings are not elastic Both form rigid support at bladder neck Move very little – 1 to 2 mm only Produce proximal compression More likely to be obstructive Mersilene more likely to erode

21. 排尿障礙治療中心 版權所有 TVT – tension-free vaginal tape First published 1996 by Ulmsten >200,000 performed worldwide to date Innovative in: –Midurethral positioning –Stretchable woven Prolene™ mesh –Rough edge for fixation to tissues –Local or regional anaesthesia / day surgery

22. 排尿障礙治療中心 版權所有 MECHANICAL PROPERTIES OF IMPLANT MATERIALS

23. 排尿障礙治療中心 版權所有 Obstruction of TVT Sling

24. 排尿障礙治療中心 版權所有 Operative success rate in SUI TVTColpoPVS Cure rate <12 months 80-100%84-100%64-100% Cure rate 1-3 yr 80 –95%84%82% Cure rate >3 yr 85%84%83%

25. 排尿障礙治療中心 版權所有 Prolene mesh Pubovaginal sling procedure 64 patients, aged 37 – 82 years Mean follow-up 24 months 52 were dry, 2 were dry after a second sling, 10 had improvement but mild SUI Satisfactory rate 86% Persistent DI in 3, resolution of DI in 3, De novo DI in 4

26. 排尿障礙治療中心 版權所有 Polypropylene mesh sling

27. 排尿障礙治療中心 版權所有 Techniques in performing prolene mesh pubovaginal sling

28. 排尿障礙治療中心 版權所有 Urodynamic results after pubovaginal sling procedure Mean ( SD ) variable A ( before )B (at 7 days )C (at 3 months )P<0.05 Q max (mL/s) 13.0(7.3)13.1(6.5)17.5(5.7)A vs C,B vs C Capacity (mL) 275(113)253(61.32)269(67.1)NS P det (cmH 2 O) 20.3(10.5)21.9(10.3)21.3(7.1)NS BN opening time (s) 8.5(8.1)24.3(27.1)12.1(10.3)A vs B Residual vol. (mL) 47.9(53.7)38.5(62.1)15.7(23.9)NS

29. 排尿障礙治療中心 版權所有 Videourodynamic results after Pubovaginal sling procedure

30. 排尿障礙治療中心 版權所有 Detailed surgical techniques for Prolene pubovaginal sling

31. 排尿障礙治療中心 版權所有

52. Bladder neck after Pubovaginal sling procedure

53. 排尿障礙治療中心 版權所有 Transrectal sonography after PVS Incompetent Bladder Neck Symphysis pubis Urethra * * Sling B A Bladder Neck Urethra Preoperative Postoperative Symphysis pubis

54. 排尿障礙治療中心 版權所有 Histology of prolene mesh sling

55. 排尿障礙治療中心 版權所有 Injection Therapy for ISD Facilitate coaptation of urethral mucosa Create some degree of outlet obstruction De novo urge in 12.6 – 28% 3% of patients had allergic reaction A second injection is needed in 11-25% A higher failure rate in fat injection The depth of injection relates to success rate

56. 排尿障礙治療中心 版權所有 Surgical Therapy for SUI Sling and retropubic procedures had 82- 84% success rate beyond 48 months Needle suspension 65-70% success Sling appears to be the most efficacious over time for all types of SUI Success rate should be determined at least 24 months after procedure

57. 排尿障礙治療中心 版權所有 Complications of Sling procedure Bladder perforation De novo urge incontinence Urinary retention after operation Sling erosion and infection Granuloma formation in vaginal wall Abdominal wall herniation Persistent wound pain and lump sensation

58. 排尿障礙治療中心 版權所有 How to prevent surgical failure Accurate diagnosis of types of SUI before operation Concomitant correction of cystocele and vesiceral prolapse Minimal dissection of suburethral endopelvic fascia Properly identify the bladder neck Hemostasis and sterile surgical procedures Adjust the suspension tension to avoid obstruction

59. 排尿障礙治療中心 版權所有 Low contractility in patient with SUI with cystocele

60. 排尿障礙治療中心 版權所有 Recurrence of Incontinence Identify the cause of recurrent incontinence Investigate anatomical defects in urethra Use of prolene mesh for definite correction Treating denovo urge with anticholinergics Release of sling if presence of obstruction Apply a second sling for persistent ISD after the first anti-incontinence surgery

61. 排尿障礙治療中心 版權所有 A second sling to cure persistent stress incontinence due to ISD Sling1 Sling2 Urethra Synphysis pubis Bladder Sling1 Sling2 Urethra Synphysis pubis

62. 排尿障礙治療中心 版權所有 When urine retention develops Pressure flow study to determine the cause Most of patients can void within 2 weeks On CISC or trocar cystostomy for training Give alpha-blocker and baclofen Give NSAID to eradicate inflammation and relieve wound pain Have more patience than the patients do

63. 排尿障礙治療中心 版權所有 Postoperative Outlet Obstruction An elevated and semi-open bladder neck without difficulty in cystoscopy will prevent Patients present with dysuria, urge, and large residual urine High detrusor pressure and low flow rate Transrectal sonography to detect angulation Lysis of sling tension can be performed within 7 postoperative days

64. 排尿障礙治療中心 版權所有 Adequate thickness of endopelvic fascia prevent sling compression Urethral Striated muscle Incompetent urethra Sling AB Urethral Striated muscle Competent urethra Sling

65. 排尿障礙治療中心 版權所有 Videourodynamics in Post- incontinence surgery BOO

66. 排尿障礙治療中心 版權所有 Transvaginal urethrolysis A tolerable way to relieve sling tension Midline vaginal incision under local anesthesia Find the sling and cut it at midline Suture the sling edges to prevent complete slippage of the sling A high continence rate remains

67. 排尿障礙治療中心 版權所有 Management of areflexic bladder following incontinence surgery Pressure flow to determine cause of SUI Avoid incontinence surgery in low compliant bladder Use of fascial sling instead of EBNS Select a procedure easy for urethrolysis Apply the sling loosely at proximal urethra Teach patient to use CISC for evacuation