Stress-inkontinenssin leikkausindikaatiot ja menetelmät Antti Valpas Ylilääkäri, LT E-K.K.S Synnytykset ja naistentaudit GKS, Helsinki 25-26.9.2008
South-Karelian Central Hospital Lappeenranta Finland
A balanced assessment of meta-analysis results and personal clinical experience remains the best approach to the challenge of SUI treatment. Elisabetta Costantini Urology Department, Univ. of Perugia, Italy Comment on Eur Urol 2007;52:678
Number of incontinence operations in women in Finland 1987-2004 3500 3000 2500 Total TVT 2000 TOT Slinga 1500 Othe r oper Othe r Burch 1000 500 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Diagnostinen jatkumo stress inkontinenssi mixt inkontinenssi urge inkontinenssi Virtsainkontinenssi on OIRE ei diagnoosi
Käypä Hoito www.terveysportti.fi Naisten virtsankarkailun hoito Ponnistusinkontinenssi voidaan hoitaa leikkauksella, ellei konservatiivinen hoito tuota riittävää vastetta.
Let s keep it simple.
Kliinisiä kriteerejä potilasvalinnalle 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ikä < 65 v ei rakon toimintaan vaikuttavia perussairauksia ei rakon toimintaa vaikuttavia lääkityksiä UISS > 50 % (> 10/20) haitta-aste kaavake US < 7 riskipiste kaavake positiivinen stress testi (rakon täyttöaste??) residuaali < 100 ml rakkokapasiteetti > 300 ml (virtsaamispäiväkirja) BMI<32 konservatiivinen hoito ei tuota riittävää tulosta
Urogyn plk strukturoidut kaavakkeet, virtsaamislista katetroidaan potilas - residuaali status 300 ml täyttö stress test dg hoitopäätös obs: kustannustehokkuus
Tutkimustuloksia yksinkertainen lähestymistapa Kiilholma P, Laurikainen E et al. Jorvin aineisto A.V:n henk. koht. kokemus
Laurikainen E, Kiilholma P. TVT procedure for female urinary incontinence without preoperative urodynamic evaluation, J Am Coll Surg 2003 Apr;196(4):579-83 N=191 dg:...was based on incontinence symptoms and pelvic examination including cough stress test or transperineal ultrasonography or both, but without preoperative urodynamic verification. 66% stress urinary incontinence 34% mixed incontinence very heterogeneous material (previous surgery etc.) Cure rates: 97% among stress urinary incontinent patients 69% among mixed incontinence patients
Jorvin urogyn tuloksia - TVT Keskiviikkomeeting 24.1.2007 Tapio Väyrynen
Subjective outcome UD- (n=210) UD+ (n=142) Cured 77% 71% NS Improved 19% 23% NS Failure 4% 6% NS UISS 60 -> 7 66 -> 10 NS VAS 72 -> 10 71 -> 13 NS Satisfied 90% 87% NS
Leikkausmenetelmät mini-invasiiviset slingat, MUS (mid-urethra tapes) TVT (Tension-free Vaginal Tape) TOT (TransObturatorius Tape: outside in) TVT-O (TVT- Obturatorius: inside out) Injektio tekniikat (esim. Bulkamid ym.) One-incision slings??
Burch colposuspension
The Mid-Urethra Concept
The Mid-Urethra Concept
Klassinen TVT
Anatomy 2. - safety
The TOT Subfascial Hammock TVT (dotted) TOT (solid) restores anatomical pubourethral ligament support like the TVT Pubovaginal Sling TOT & Normal PU Ligament LA = Levator Ani U = Urethra V = Vagina
What is the best sling for stress urinary incontinence? Antti Valpas MD, PhD, Head of the Department Department of Obstetrics and Gynecology South-Karelian Central Hospital Lappeenranta, Finland NFOG 2008, Reykjavik
Recent meta-analyses Dean N, Herbison P, Ellis G, Wilson D. Laparoscopic colposuspension and tension-free vaginal tape: a systematic review. BJOG 2006;113:1345-1353 Latthe PM, Foon R, Tootz-Hobson P. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. BJOG 2007;114:522-531 Novara G, Ficarra V, Boscolo-Berto R, Secco S, Cavalleri S, Artibani W. Tensionfree midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials of effectiveness. Eur Urol 2007;52:663-679 Sung VW, Schleinitz MD, Rardin CR, Ward RM, Myers DL. Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis. Am J Ob & Gyn July 2007:3-11
Latthe PM, Foon R, Tootz-Hobson P. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. BJOG 2007;114:522-531 TVT vs. TVT-O: 5 studies TVT vs. TOT: 6 studies the primary outcome in all trials was cure measured and reported in a variety of ways follow-up: 2-12 months
Subjective cure: retropubic routes vs. transobturatorius routes
Complications: TVT vs. TOTs
2. MUS mid-urethra slings - results of TVT studies prospective observational cohort studies reveals that cure rates between 80-90% can be achieved in different groups of incontinent women primary cases (Ulmsten et al. 1996, Ulmsten et al. 1998, Nilsson 1998, Ulmsten et al. 1999, Nilsson et al 2001) recurrent cases (Rezapour and Ulmsten 2001, Kuuva and Nilsson 2003) mixed incontinence (Rezapour and Ulmsten 2001) unselected group (including ISD, low pressure urethra) (Nilsson and Kuuva 2001) long term up to10 years (Nilsson CG, Palva K et al. 2008)
TVT better than TOT in short term? retrospective cohort study, fo min 6 months N=464 : TVT N=252 vs. TOT N=212 multivariate analysis 4 independent risk factors for persistent stress urinary incontinence: comorbid disease (OR 2.37, 95% CI 1.26-4.47, p=0.008) urge urinary incontinence (OR 1.95, 95% CI 1.02-3.74, p=0.044) severe grade of cystocele (OR 2.73, 95% CI 1.43-5.20, p=0.002) TOT procedure (OR 2.87, 95% CI 1.50-5.47, p=0.001) Paick J-S et al. Factors influencing the outcome of mid urethral sling procedures for female urinary incontinence. J Urol 2007;178:985-989
RCTs comparing TVT vs.tvt-o N Follow-up Main outcome / conclusions Zullo 2006 72 12 -equally effective -TVT-O faster / less complications Meschia 2006 231 6 Liapis 2006 91 12 -succes rates comparable Aroco 2008 208 12 -in severe cases TVT sign. better(100% vs. 66%, p<0.001) Rinne 2008 273 12 -no sign. difference between the groups -equally effective -bladder perf.4 % in TVT / 0% TVT-O
RCTs comparing TVT vs. TOT N Follow up (months) Main outcome / conclusions Andonian et al. 2006 190 12 -no sign.differences in Porena et al 2007 -obs. Obtape 148 31 -no differences in cure rates -no diff. in complication rates cure rates -more postoperative compl. with Obtape and DUPS
RCTs comparing TVT-O vs. TOT N Follow-up (months) Main outcome / conclusions But I, Faganelj M 2008 120 3 -equally succesfull -TVT-O more painfull Liapis A et al. 2008 120 12 -MONARCH technique presents success / complication rates equal to TVT-O at 1 year fo Lee et al. 2008 100 12 -equally effective
Low pressure urethra, ISD Study design O Connor RC et al. 2006 retrospective cohort (TVT-0) Miller J-J et al.2006 historical cohort - VLPP 60 cm H2O N 43 Follow-up (months) 6 used as cutt- off level - MUCP 42 cm H2O used as cutt-off level 145 -MONARCH N=85 -TVT N=60 3 Main outcome / conclusions -overall cure rate 65% VLPP > 60 cm H2O: 77% cured VLPP < 60 cm H2O: 25% cured -MUCP< 42 cm H2O MONARCH nearly six times more likely to fail than TVT O Connor R, Nanigian D, Lyon M et al. Early outcomes of mid-urethral slings for female stress urinary incontinence stratified by valsalva leak point pressure. Neurourol Urodyn 2006;25:685-688 Miller J-J, Botros S, Akl M et al. Is transobturator tape as effective as tension-free vaginal tape in patients with borderline maximum urethral closure pressure? Am J Obstet Gynecol 2006;195(6):1799-1804
Repeat MUS after initial MUS cure rates vary after one year fo (N=31): TVT 92.3% TVT-O 75% TOT 50% after TOT sling failure 17 mo fo with TVT all cured (N=5) Lee K-S et al. Outcomes following repeat mid urethral synthetic sling after failure of the initial sling procedure: rediscovery of the tension-free vaginal tape procedure. Urology 2007;178:1370-1374 Moore RD et al. Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure. Int Urogynecol J 2007;18:309-313
Future aspects Bulk Amid injektiot One Incision experimental surgery!!! TVT Secure Mini Arch etc. Sigurd (Norge s Tutte): registry unpublished data: TVT better than TOT?
Yhteenveto 1. Leikkausindikaation asettelussa ja menetelmän valinnassa huomioitava ja yksilöllisesti arvioitava kokonaistilanne 2. TVT ja TOT tekniikat yhtä tehokkaita lyhyellä aikavälillä 3. Vakavia komplikaatioita (suoliperf., suuret vuodot) todennäköisesti vähemmän TOT tekniikoilla 4. TVT saattaa olla parempi joissakin erityistilanteissa (residiivi, matalapaine urethra)