Urogynae Flashcards

Question

Surgical interventions for UUI

Answer 1

Aims - increases bladder capacity, modifies innervation and contractility of destrusor muscle, or bypasses lower urinary tract Risks: self catheterization Sacral nerve root stimulation Botox Augmentation cystoplasty Detrusor myomectomy Urinary diversion Tibial nerve stimulation. This is designed to stimulate the nerves that control bladder function via a nerve which passes around the ankle. It involves inserting a small needle near the ankle, which is connected to a device that stimulates the tibial nerve. This indirectly stimulates and retrains the nerves that control the bladder.

Answer 2

P - Inhibits sacral bladder reflex by chronic electrical stimulation of S3 roots. A small stimulator device is implanted under the skin just above the buttocks. A wire carries electrical impulses to the sacral nerves. A hand held programmer can switch the device on or off. 2 stage procedure - performed under local anaesthesia and sedation or GA. 3 incision in lower back. A permanent electrode is placed under the sacral nerve and a temporary lead is connected to the electrode, tunneled under the skin adn tbrought out to the oppsite side where it is connected to an external control device. the initial test phase requires a 2-8 week assessment to see the response and then a permanent device is inserted as the second stage. 1-2 day stay in hospital, under GA. Permanent neuromodulator battery is placed under skin in back just above buttocks. Device switched on with handset. No external wires. R - OAB / DO E - No sex, excessive bending, stretching as may displace device in first stage. Can experience tingling, tapping, dragging etc from urethra to anus. Need ot complete bladder diary. Second stage 1-2 day in hospital. Battery alsts 15 years P - 63% A - Anti cholinergics, botox, urinary diversion R - pain, skin irritation, infection, device problems, uncomfortable stimulation, lead movement, infection, occ: temporary weakness of leg. Technical problems. Can cause security alarms to go off e.g. airports. Can't have MRI etc. Diving not okay. Also good for faecal incontinence, chronic bladder pain, interstitial cystitis.

Answer 3

P - Botox - prevents awareness of when the bladder starts to fill. Cystoscopy, inject local anaesthetic in ~20-30 places. R - OAB / DO E - day case procedure under local, spinal or general, lasts 3-9 months. If under spinal or local anaesthetic can have minor discomfort during the procedure. Should drink plenty of fluid over next few days. Can have stinging or burning following procedure. P - 60% chance of achieving significant improvement in urinary urgency and urge A - sacral nerve modulation, solifenacin, bladder retraining R - Haematuria, urinary retention with self catheterization (3-10%), urine infection 10%, allergy and anaphylaxis, erythema multiforme (severe skin rash), generalized weakness. E - written info

Answer 4

Duloxetine - serotonin and NA reuptake inhibitor - for moderate to severe SUI. Increases pudendal nerve activity, thus increasing urethral sphincter closure. Not available in NZ. Nausea significant SE

Answer 5

TVT Burch colposuspension Transobturator tape intramural bulking agents Autologous fascial slings

Answer 6

P - TVT: suburethral sling placed for support. Once sling is in place, supporting connective tissue grows through the holes in the mesh weave to anchor the sling in position. Retropubic route Transobturator Route: incision medial to groin Mini sling - similar to TVT or TOT but shorter strip of mesh - long term studies lacking R - SUI E - 1 night in hospital, IDC, no heavy lifting, intercourse, sports for 6 weeks, 2-4 weeks off work P = 80-90% (similar to burch) A - Autologous sling, bulkamid, birch colposuspension, continence devices e.g. large tampon when exercising, insertion artificial urinary sphincter R - UTI, bleeding, voiding difficulty (1-5% - often due to swelling and will settle down. May need to self catheterize 2%), mesh exposure 2-4%, bladder or urethral perforation (1-5% TVT, 1% TOT) Urgency and urge incontinence (50% will have improvement in UUI but 5% will have worse symptoms), pain (1% in TVT, 10% in TOT - usually 1-2 weeks only), tape too tight and need cut in a second operation or too loose and not work

Answer 7

Pre op evaluation for fitness for surgery Informed consent Sign in: introductions, patient risk factors, HCG status, allergies GA Abx WHO time out Lithotomy Prep and drape BM Local anaesthetic with adrenaline infiltrated suburethra, bilaterally vaginally from midline to pubic rami in endopelvic fascia and suprapubic to skin Small incisions suprapubic In and out catheter 1-2cm vertical incision below external urethral meatus under mid urethra Sharp and blunt dissection to develop tunnel at 45 degree angle out to posterior aspect of pubic rami Rigid guide placed in 18 french catheter and passed into urethra to bladder neck Guide directed towards side of insertion to deviate bladder away from trocar Trocar with attached mesh placed retropubically, first passing in lateral direction, then guided up towards ispilateral shoudler hugging posterior pubic ramus to appear suprapubic in your incision Cystoscopy performed to check no perforation Second side done and cystoscopy performed again - trocars removed and mesh pulled through Tape tightened over 8-heger dilator and plastic covering removed Excess tape cut flush with skin skin incision closed vagina closed with 2-0 vicryl locked for additional haemostasis IDC placed No pack unless issues with bleeding Post procedure - Remove IDC day 0 Measure of void and PVR x 1 home following day ovestin Early mobilization Thromboprophylaxis Pain management E+D as tolerated Consider routine laxatives Debrief Post op instructions: driving, constipation, heavy lifting Clinic FU 4-6 weeks Troubleshooting: bladder perf 2-4% - remove and replace trocar, IDC 48h, IV abx Urinary retention - IDC 48h and then 7/7 and then ISC or SP catheter, and cut tape at 14/7

Answer 8

Similar sucess rates TOT higher failure rate TOT lower visceral injury

Answer 9

P - Operation that involves placing sutures in the vagina on either side of the urethra and tying them to ileopectineal ligament to elevate the vagina R - SUI E - Laparotomy vs laparoscopy, cystosocpy. Sometimes drain or suprapubic catheter used. 6/52 off work P - 80% improvement or cured, 60% at 20y A - TVT, TOT, autologous fascial sling R - haemorrhage, infection, VTE, GA risks. failure to work (20% at 1 year), OAB 17%, voiding difficulties 10%, posterior compartment prolapse 14%, dysapareunia, suture erosion - Compared with midurethral slings o Advantages  Long term effectiveness comparable to mid urethral slings  Less bladder injury  No mesh o Disadvantages  Increased de novo urinary urgency  Injury to adherent obturator  Longer hospital stay  Longer return to ADLs  Complications / morbidity associated with laparotomy  More expensive  Longer operating time

Answer 10

Pre op evaluation for fitness for surgery Informed consent Sign in: introductions, patient risk factors, HCG status, allergies GA Abx WHO time out Lithotomy Prep and drape BM Pfannenstiel 5cm incision Retropubic space exposed and peritoneum swept superiorly Periurethral fat removed for adequate visualisation of the anterolateral vaginal wall Foleys catheter inserted per urethra and balloon inflated 2 or 3 absorbable sutures placed through the endopelvic and vaginal fascial complex adjacent to the urethra and attached to coopers ligament loosely, tension free manner. Cytoscopy then perform and abdomen closed Post procedure - Remove IDC and pack day 1 Measure of void and PVR x 1 Early mobilization Thromboprophylaxis Pain management E+D as tolerated Consider routine laxatives Debrief Post op instructions: driving, constipation, heavy lifting Clinic FU 4-6 weeks

Answer 11

P - Fascia is a strong connective tissue that is obtained from abdomen or thigh, 1-3cm wide, placed under urethra R - SUI E - 1-2 nights in hospital, small laparotomy scar, IDC P - 80-90% A - TVT, TOT, burch R - wound infection, bladder infection, VTE, pain, discomfort, bleeding, voiding diifculty (5% need to learn how to self catheterize), fascial exposure, bladder or urethral damage, UUI, pain

Answer 12

Same as TVT but harvest rectus fascia or fascia lata Develop space of rectius Then put long kelly clamp from abdomen to vagina and grasp sling, bilaterally Prolene sutures that are attached to each edge of sling are brought out through lower leaf of rectus fascia on both sides Rectus closed with loop nylon Prolene sutures are tied to each other and tightened over a kelly's clamp (to avoid overtightening) As effective as TVT

Answer 13

P - Bulking agent around urethra. Common agents include collagen and water based gels R - SUI, women not fit for a bigger surgery or want a less invasive approach. Women whose stress incontinence is due to mainly a deficiency int he sphincter surrounding the urethra E - Day procedure, no incisions or cuts, can be performed under local anaesthetic P - 65% A - TVT, TOT, Burch, PFMT, pessary R - GA, bleeding and infection, pain on passing urine, voiding difficulty (10%), need for repeat procedure - top up, allergy, abscess, granuloma

Urogynae Flashcards

(38 cards)