Surgical Management of Female Urinary Incontinence Incontinence

Transcription

Incontinence 尿失禁
Surgical Management of
Female Urinary Incontinence
• Involuntary leakage of urine
• 1 in 4 women : 1 in 9 men
will suffer from urinary incontinence
at some stage of their lives
• Incidence increases with age
Dr Bill WONG
Specialist in Urology, Pedder Clinic
Hon Consultant Urologist, Queen Elizabeth Hospital
Hon Director, Urology Centre, St Paul’s Hospital
Hong Kong
Lower Urinary Tract 下尿路
Bladder & Outflow Tract
Anatomy
Normal Functions
Male
• Storage of urine
Female
• Capacity
• Detrusor
• End-filling pressure
• Closure mechanisms
• Voiding urine
• Detrusor contraction
• Bladder outlet
• Post-void residual
400 - 500 ml
stable
Pdet < 15 cmH2O
adequate
Pdet 40 - 60 cmH2O
patent
0 ml
Urinary Incontinence
Etiology
Definition
Bladder
Outflow Tract
Storage
• Overactive bladder
• Non compliant bladder
• Small fibrotic bladder
• Incompetent sphincter /
outflow tract
• Fistulae
Voiding
• Chronic retention w/
overflow
• BOO (eg BPH)
• Dysfunctional outflow
(eg post RT)
• Involuntary loss of urine, which is a social
or hygienic problem, and which is
objectively demonstrable
International Continence Society, 1988
• Involuntary loss of urine, which is sufficient
to be a problem
Urinary Incontinence Guideline Panel, 1992
Agency for Health Care Policy and Research
U S Department of health and Human Services
*
1
Problem Oriented Grouping
Prevalence in Elderly
• Enuresis in children
• Stress incontinence in women
• Incontinence in elderly - men
- women
• ~ 30 % of population older than 60 years
• > 50 % of institutionalised elderly persons
resident in nursing home
Resnick, et al NEJM 320:1-7, 1989
Economic Costs
Terminology 分類名稱
• Costs related to urinary incontinence
in 1995
US$ 26.3 billion
US$ 3,565 per patient
Wagner, Hu Urol 51:355-61, 1998
• Urge incontinence
急切性
• Stress incontinence
壓力性
• Overflow incontinence 滿溢性
• Total incontinence
• Functional incontinence
Urge Incontinence 急切性尿失禁
Stress Incontinence 壓力性尿失禁
• Loss of urine, with urge to urinate and yet
inability to postpone voiding
• 2 types :
- Motor urgency
• Leakage of urine, with activities that
increase abdominal pressure such as laughing, coughing, sneezing &
positional changes
accompanied by urodynamically documented
involuntary / uninhibited detrusor contraction
- Sensory urgency
2
Stress Urinary Incontinence
Stress Incontinence 壓力性尿失禁
International Continence Society Terminology
• Genuine stress incontinence
(in women)
Urodynamic stress incontinence
• Stress incontinence related to detrusor instability
• Urodynamic stress incontinence
Loss of urine as a result of an abdominal pressure increase,
without detrusor overactivity, during storage phase of
urodynamic testing
• Detrusor overactivity incontinence
Loss of urine as a result of involuntary detrusor activity,
during storage phase of urodynamic testing
• Urodynamic mixed incontinence
Urodynamic stress incontinence in combination with
detrusor overactivity incontinence
Overflow Incontinence 滿溢性尿失禁
Investigations
• Leakage of urine, at greater than bladder
capacity;
associated with incomplete bladder
emptying, due to either impaired detrusor
contractility or bladder outlet obstruction
• History taking
• Voiding diary / frequency volume chart
• Urodynamic study
International Continence Society, 1997
Voiding Diary 日記
or Frequency Volume Chart
Voiding Diary 日記
or Frequency Volume Chart
3
Urodynamics 尿流動力學
Urodynamic Study
Video Urodynamic Study
Etiology
Bladder
Outflow Tract
Storage
outflow tract
• Fistulae
Voiding
overflow
• BOO (eg BPH)
(eg post RT)
4
Bladder Storage
3 ‘C’s
• Capacity
• Compliance
• Contractions
- a capacious reservoir
- to store urine at low pressure
- w/out involuntary contractions (ie stable bladder)
Unstable / Overactive Bladder 膀胱過動
A6378822
Urodynamic Definition
• An involuntary rise in detrusor pressure
during bladder filling of 15 cmH2O or more
International Continence Society Standardisation Committee
Urge Syndrome
Detrusor Instability
• The ‘unstable bladder’ may be defined
as a bladder which does not tolerate
filling, contracting without its owner’s
permission.
Clinical Features
•
•
•
•
Urgency
Frequency
Nocturia
Urge incontinence
尿急
尿頻
夜尿
急切性尿失禁
McGuire EJ Urol Clin N Am 5:335, 1978
5
Urge Syndrome
Clinical Features
•
•
•
•
Urgency
Frequency
Nocturia
Urge incontinence
尿急
尿頻
夜尿
急切性尿失禁
Overactive Bladder 膀胱過動
Urge Syndrome
Clinical Features
•
•
•
•
Urgency
Frequency
Nocturia
Urge incontinence
尿急
尿頻
夜尿
急切性尿失禁
Causes
•
•
•
•
•
•
•
•
Cystitis
Bladder stone
Bladder tumour
Bladder outlet obstruction - substantially higher incidence
Idiopathic - up to 10 % of population
Children
substantially higher incidence
Elderly
Neuropathic bladder / detrusor hyperreflexia
]
× Bladder / ‘catheter’ spasm
Management
Management
• Treatment of underlying cause (if any)
• Control of detrusor overactivity
• Conservative measures / first-line management
• Drug therapy
• Surgical intervention
• Drug therapy
6
Overactive Bladder
Drug Therapy
1
Overactive Bladder
Drug Therapy
• Anticholinergic
2
• Anticholinergic (* cont’d)
- Propantheline (Probanthine)
- Emepronium (Cetiprin Novum)
..… / cont’d *
- Oxybutynin (Ditropan)*
- Tolterodine (Detrusitol)*
- Solifenacin (Vesicare)*
• Anticholinergic + Ca++ channel blockade
• Smooth muscle relaxant
- Flavoxate (Urispas)
- Propiverine
• Anticholinergic + α-adrenergic
- Imipramine (Tofranil)
Overactive Bladder
Overactive Bladder
Oxybutynin vs Tolterodine
Oxybutynin vs Tolterodine
Mean change from baseline in :
Frequency & severity of dry mouth
Frequency of micturitions No. of incontinence episodes
in 24 h
in 24 h
Volume voided
per micturition
Time (weeks)
Placebo (dark green)
Tolterodine 2mg bd (light green)
Oxybutynin 5mg tid (pink)
Abrams et al BJU 81:801, 1998
Abrams et al BJU 81:801, 1998
Overactive Bladder
Overactive Bladder
Tolterodine + Simplified Bladder Training
Tolterodine + Simplified Bladder Training
• Simplified bladder training (BT) = Written information sheet
• Tolterodine 2mg bd + simplified BT vs Tolterodine alone →
• median % ↓ in voiding frequency
33% vs 25%
• median % ↑ in volume voided per void 31% vs 20%
• No significant difference in
• median % ↓ in incontinence episodes
• median % ↓ in urgency episodes
Mattiasson, et al & Tolterodine Scandinavian Study Group
BJUI 91:54, 2003
• Conclusion:
• Simplified bladder training augments effectiveness of
tolterodine in patients with overactive bladder
• Caveats:
• Insufficient time, funding or qualified staff in clinics
→ Lack of extensive personal interaction
• Patient motivation & mental capability
Mattiasson, et al & Tolterodine Scandinavian Study Group
BJUI 91:54, 2003
7
Overactive Bladder
Solifenacin
Management
• Bladder selectivity
Drug
Selectivity ratio
(Bladder selectivity over salivary glands)
Solifenacin (Vesicare)
Tolterodine (Detrusitol)
2.1 *
0.65
Oxybutynin (Ditropan)
0.51
• Drug therapy
* p<0.1 (statistically different from Tolterodine & Oxybutynin)
• Phase I studies showed no decrease in salivary flow with
Solifenacin 5 mg
• Once daily dose regimen
• 5 – 10 mg daily
Uchida, et al (2004)
•
•
•
•
•
Incontinence
Incontinence
Conservative Management
Behavioral modification 行為治療
Bladder retraining 膀胱訓練
Physical therapies 物理治療
Incontinence aids & appliances 尿遺用品
Clean intermittent self catherisation (CISC)
清潔間歇性自助導尿術
•
•
•
•
•
Detrusor Overactivity
Management
Surgical Treatment
• Drug therapy
•
•
•
•
•
•
•
Prolonged bladder distension
Transvesical injection therapy
Sacral neurectomy
Sacral nerve stimulation / Neuromodulation
Bladder transection
Detrusor myomectomy / Bladder autoaugmentation
Entero-cystoplasty / Bladder augmentation
8
Intravesical Therapy
Intravesical Capsaicin
• Intravesical instillation of capsaicin
• Intravesical Botulinum-A toxin injection
Botulinum-A Toxin Injection
• Botulinum-A neurotoxin binds to pre-synaptic terminal of motor neurons
→ selectively inhibits acetylcholine release at neuromuscular junction
→ detrusor hypocontractility
↓ intravesical pressure
• Botox® 300 u in n-saline 30 ml
Dysport® 750–1000 u in n-saline 20 ml
Toxin equivalence - Botox : Dysport = 1 : 2.5
• Fill bladder to 100–200 ml
Inject into bladder wall, sparing trigone
½–1 ml per site
Refractory Detrusor Overactivity
Surgical Treatment
• Effect lasts 9 – 12 months
• Repeat injections are as effective
Grosse, et al Eur Urol 47:653,2005
• Advantage:
• Non invasiveness
• Disadvantages:
• Transient muscular weakness
• Drug resistance
•
•
•
•
•
•
•
Prolonged bladder distension
Transvesical injection therapy
Sacral neurectomy
Sacral nerve stimulation / Neuromodulation
Bladder transection
Detrusor myomectomy / Bladder autoaugmentation
Entero-cystoplasty / Bladder augmentation
9
Neuromodulation
Detrusor Myectomy
• Removal of overlying
detrusor muscle creates
‘diverticulum’
• Results in fibrosis
• May be offered for urinary incontinence or irritative symptoms
due to refractory detrusor overactivity
• Mechanism of action unknown
• Predictors of outcome & patient response unknown
Level of Evidence: 2 - 3
Grade of Recommendation: B
3rd Int’l Consultation on Incontinence, 2004
Bladder Autoaugmentation
Bladder Autoaugmentation
Demucosalised Bowel
Detrusor Myectomy
• Idiopathic detrusor instability
or Detrusor hyperreflexia
n = 27
- Minimum 1 year followup
- Urodynamic variables showed significant improvement
- Symptomatic improvement considered inferior to that
obtained by enterocystoplasty
- Success rate higher with idiopathic detrusor instability
- 3 neuropathic patients required conversion to
enterocystoplasty
Swami et al BJU 81:68, 1998
Bladder Augmentation
Enterocystoplasty for Refractory Urge Incontinence
Enterocystoplasty
Detrusor
overactivity
Good or
moderate result
Bowel segment
Clam ileo-cystoplasty
Bramble (1982)
15
13
13 colon. 2 ileum
Mundy, Stephenson BJU 57:641,1985
Mundy & Stephenson (1985)
40
30
ileum
Sethia et al (1991)
11
9
ileum
Hasan et al (1995)
33
19
ileum, colon
44
McInerney et al (1995)
50
Leng et al (1999)
2
2
Edlund et al (2001)
25
19
176
136 ( 77 % )
Total
10
Enterocystoplasty
Enterocystoplasty
• Complications:
• Mucus plug retention
• 10 % (minimum) require intermittent catheterization
for bladder emptying
• Idiopathic urge incontinence
-
n = 51
53 % happy with outcome of surgery, 39 % not happy
39 % required CISC
18 % continued to have incontinence
Awad et al BJU 81:569, 1998
• Neurogenic LUTD (mostly incontinence)
- n = 59
- 58 / 59 ‘delighted’, ‘pleased’ or ‘mostly satisfied’
- 40 % had complications at 70 months median followup
Herschorn, Hewitt Urol 52:672, 1998
Enterocystoplasty
• Patients with idiopathic & neurogenic urge
incontinence may have quite different expectations
of the results of surgery
• Generally considered a treatment of last resort for
idiopathic detrusor instability
Continent Urinary Diversion:
Mitrofanoff Principle
• Catheterisable conduit to a
urinary reservoir
• With a continent and
catheterisable cutaneous stoma
Cystostomie continente trans-appendiculaire
dans le traitement des vessies
neurologiques.
Mitrofanoff P Chir Pediatr 21: 297, 1980
Mitrofanoff Principle
Urol Clin N Am 24:796, 1997
11
Etiology
Bladder
Outflow Tract
Storage
outflow tract
• Fistulae
Voiding
overflow
• BOO (eg BPH)
(eg post RT)
Lower Urinary Tract 下尿路
Anatomy
Female
Video Urodynamic Study
Urodynamic Stress Incontinence
in Women
女性壓カ性尿失禁
Pelvic Floor Support
• Levator ani muscle
• Levator fascia
• Fascial ligaments
A640338A TamFY F / 56
9911-062 Δ GSI Type I
Filled to capacity (485 ml)
→
Coughing
12
K2981459 ChauHM F / 53
9909-044 Δ GSI Type II
Filled to capacity
Female SUI
→
Valsalva
Pathophysiology
Decrease in bladder outlet / urethral resistance
due to:
• Poor anatomical support of bladder neck –
urethral hypermobility
• Impairment of urethral function / closure –
intrinsic sphincter deficiency
• Combination of both
Radiological Classification
Blaivas & Olsson
Type
At Rest
0
Absence of GSI
BN hypermobility <2 cm
At Strain
I
BN closed
BN open
BN hypermobility <2 cm
IIa
BN closed
BN above inferior margin of
pubis
BN open
BN hypermobility =/>2 cm
IIb
BN closed
BN below inferior margin of
pubis
BN open
Further descent
III
BN & proximal urethra open
Blaivas J Urol 139:727:1988
Childbirth - Vaginal Delivery
Pelvic Floor Damage
Vaginal Weakness
13
Weakened Levator Hiatus
Muscle Denervation
Vaginal Mobility
Incontinence
Loss of Anatomic Support
•
•
•
•
•
14
Surgical Treatment
Marshall-Marchetti-Kranz Procedure
• Retropubic suspension procedures
• Marshall-Marchetti-Krantz (MMK)
• Burch colposuspension
• Laparoscopic colposuspension
• Transvaginal suspension procedures
• Transvaginal needle suspensions
• Pubovaginal sling
• Tension-free vaginal tape
• Artificial urinary sphincter implant
Marshall-Marchetti-Kranz Procedure
Recommendations
Burch Colposuspension
• Longer-term outcome is poor following MMK,
and declines further over time
Level of Evidence: 1
• MMK procedure is not recommended for the
treatment of SUI in women
Grade of Recommendation: A
4th Int’l Consultation on Incontinence, 2008
Burch Colposuspension
Colposuspension – Variations
Raz Bladder Neck Suspension
15
Colposuspension – Variations
Open Burch Colposuspension
Vagino-Obturator Shelf Procedure
Results
Open Burch Colposuspension
Laparoscopic Colposuspension
Recommendations
Recommendations
• Open retropubic colposuspension is an effective
treatment for primary SUI, which has longevity
• Open colposuspension should still be considered
when an open abdominal procedure is required
concurrently with surgery for SUI,
although it has to a large extent been superseded
by the less invasive mid urethral tapes
• Comparable subjective outcome, but poorer
objective outcome in short to medium term,
than both open colposuspension & TVT
• Longer term outcomes unknown
• Laparoscopic colposuspension is not
recommended for the routine surgical treatment of
SUI in women
Grade of Recommendation: D
Stamey Needle Suspension
16
Fascial ligaments
Needle Suspension Procedures
Pubovaginal Sling
Recommendations
• Needle suspension procedures are less effective
than colposuspension even in the short term
• Needle suspension procedures, endoscopic or nonendoscopic, with or without bone anchors, are not
recommended for the treatment of SUI in women
Pubovaginal Sling
Pubovaginal Sling
Sling Materials
Type of Material
Pros
Cons
Autologous
(fascial sling)
• Easily available
• Biocompatible
• Cost-effective
• Harvesting morbidity
(pain, wound complications)
• Longer operative time
Cadaveric
•
•
•
•
Easily available
Length & size adjustable
No harvesting
Shorter procedure
• Tensile strength unknown
• Potential risk of infection
(HIV, prions)
• Durability & efficacy
unknown
• Cost
Synthetic
•
•
•
•
Easily available
Length & size adjustable
No harvesting
Shorter procedure
• Risk of erosion into urethra,
bladder neck or vagina,
& infection
• Durability & efficacy
unknown
• Cost
17
Pubovaginal Sling
Mid Urethral Tapes
Recommendations
• Autologous rectus fascial sling is an effective
• Retropubic placement
treatment for SUI, which has longevity
*
• Further high quality research is required to clarify
the place of ‘traditional’ sling procedures in
relation to other procedures, and to establish the
optimum sling materials
• Intra vaginal sling
• Supra pubic arc sling
• Transobturator placement
• Inside-out procedure
• Outside-in procedure
TVT
IVS
SPARC
TVT-O
TOT
Grade of Recommendation: D
Pathophysiology of Female SUI
Tension-free Vaginal Tape (TVT)
Hammock Theory
Principle
Colposuspension
Endopelvic fascia connects anterior
vaginal wall to arcus tendineus
bilaterally, forming a hammock-like
support structure upon which the
bladder & urethra rest
TVT
Rises in intra-abdominal pressure
compresses the urethra against the
supporting structures, which act like
a stable backboard, & results in
occlusive action
DeLancey JO Am J Obst Gyne 170:1713,1994
Technique
Ulmsten, et al Int Urogyne J 7:81,1996
Mid Urethral Tapes
• Retropubic placement
• Intra vaginal sling
• Supra pubic arc sling
• Transobturator placement
• Inside-out procedure
• Outside-in procedure
TVT
IVS
SPARC
TVT-O
TOT
Ulmsten, et al Int Urogyne J 7:81,1996
18
Technique
Technique
Minimally invasive :
• 3 small incisions
• 1 vaginal, 1.5–2 cm long
• 2 suprapubic, @ 1 cm long
• Duration of operation
• 30–45 minutes
• Duration of hospitalization
• 1–3 days
Results
Results
Patients
Follow-up
Cure
(%)
Improved
(%)
Failed
(%)
Ulmsten
(1998)
131
1 yr
91
7
2
Ulmsten
(1998)
50
3 yr
86
12
2
Olsson
(1999)
51
3 yr
90
6
4
Haab
(2000)
62
1 yr 4 m
87
10
3
Klutke
(2000)
20
1 yr
85
10
5
Moran
(2000)
40
1 yr
80
17
3
De novo
DI (%)
6
12
Recommendations
Complications
• Retropubic TVT is more effective than Burch
colposuspension, and equally effective as
traditional fascial sling procedures
Level of Evidence: 1/2
• Operation time, hospital stay, & time to resume
normal daily activity is shorter with TVT than
with colposuspension
Multicentre prospective study
N = 100
Urinary infection
Bladder injury
10 %
6%
Prolonged pain
Complete retention >1 month
3%
1%
Retropubic haematoma
Major labial haematuria
1%
1%
Healing problems
Bleeding >200 ml
1%
1%
Haab, et al Prog Urol 10:47A, 2000
19
Intrinsic Sphincter Deficiency
Recommendations
Surgical Treatment
• Colposuspension is more commonly associated
with post-operative voiding problems & need for
urogenital prolapse surgery
• TVT is more commonly associated with bladder
perforation
• Sling operation
• Urethral bulking agents
• AUS implant
B2807039 TongLS F / 63
9901-002 Δ GSI: ISD
At capacity
Urethral Bulking Agents
Pubovaginal Sling
Periurethral Injection
• Add bulk to increase coaptation of urethral wall
at level of bladder neck / distal sphincter
• Bulking agents:
• Bovine collagen (Contigen®)
• Silicone macroparticles (Macroplastique®)
• Hyaluronic acid / dextranomer copolymer
(Zuidex®)
• Carbon coated zirconium oxide beads
(Durasphere®)
• Dimethyl sulfoxide / ethylene vinyl alcohol
copolymer (Uryx®)
• Hydoxylapatite spheres in
carboxylmethylcellulose carrier (Coapatite®)
20
Artificial Urinary Sphincter
X Indwelling Urethral Catheter
留置導尿管
•
•
•
•
•
•
•
•
•
•
尿失禁
X Urostomy
Leakage
Catheter / bladder spasm
Inability to retain catheter
Erratic drainage
Infection
Epididymo-orchitis
Pressure necrosis
Catheter tumour
Encrustation
Inability to withdraw catheter
Bladder & Sphincter Dysfunction
Priorities in Long-term Management
Shared Care 醫護分工
• Preservation of renal function
→
Quantity of life
壽命
• Alleviation of symptomatic problems
→
Quality of life
生活質素
• Urinary continence
• Stoma / appliance free
• Specialist consultation
- for investigation, diagnosis & appropriate treatment plan
• Multi-disciplinary approach in management
- urologist, urology nurse specialist & practitioner,
continence advisor, other health care providers
- eg Continence Clinic
Urology Nurse Practitioner Clinic
• Involvement of family
• Involvement of family physician & primary health
care providers
21

Surgical Management of Female Urinary Incontinence Incontinence

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