Mixed and Recurrent Incontinence, Incontinence in Patients with Pelvic Organ Prolapse, and How Best to Avoid and Manage Complications: Case Discussions

14 Mixed and Recurrent Incontinence, Incontinence in Patients with Pelvic Organ Prolapse, and How Best to Avoid and Manage Complications


Case Discussions



Mickey Karram, M.D.



W. Stuart Reynolds, M.D.



Roger Dmochowski, M.D.



image Videos



14-1. Recurrent Stress Urinary Incontinence After Two Previous Unsuccessful Synthetic Midurethral Sling Procedures


14-2. Bladder Perforation at the Time of Retropubic Synthetic Midurethral Sling Procedure


14-3. Excision of Suburethral Portion of Synthetic Sling and Partial Cystectomy to Remove Eroded Sling with Stone Formation from Bladder


14-4. Excision of TVT-Secur Sling from Urethra with Urethral Reconstruction and Placement of Cadaveric Fascial Pubovaginal Sling


14-5. Complete Removal of Transobturator Tape (OB Tape) Secondary to Recurrent Granulation Tissue and Vaginal Bleeding


14-6. Recurrent Incontinence After Tension-Free Vaginal Tape Secondary to Complex Urethral Diverticulum


14-7. Excision of Eroded Tension-Free Vaginal Tape, with Repair of Urethrovaginal Fistula and Placement of Cadaveric Fascia Pubovaginal Sling


14-8. Avoiding and Managing Bleeding During Placement of Retropubic Midurethral Sling


14-9. Avoiding and Managing Small Bowel Injury During Placement of Retropubic Midurethral Sling



Introduction


This chapter discusses the management of mixed and recurrent stress incontinence, the management of incontinence in conjunction with pelvic organ prolapse, and how best to avoid and manage intraoperative and postoperative complications that can occur when performing procedures to correct stress incontinence. These discussions are presented in a case presentation format. A video clip to demonstrate and illustrate the various complications accompanies most cases. Complications related to urinary retention and voiding dysfunction are not included in this chapter because they are discussed in Chapter 9.




Case 1: Mixed Incontinence


A 62-year-old woman presents with symptoms of severe incontinence. She describes her incontinence as being both stress and urge related. She wears numerous pads every day, and when asked whether she is more bothered by the stress or the urge component, she states they are equally bothersome. Initial attempts at nonsurgical management include antimuscarinic therapy, timed voiding, pelvic floor rehabilitation, and behavioral therapy. Although these modalities significantly improve the urge component of her leakage, she continues to complain of fairly severe stress incontinence and desires definitive therapy for this. Urodynamics testing notes readily demonstrable stress urinary incontinence (SUI) at a volume of 150 mL with leak point pressures of 80 cm H2O. She has an uninhibited bladder contraction at a volume of 500 mL that is associated with a large volume leak. The patient gives consent for a transobturator sling fully understanding that the natural history of the urge component of her leakage was unpredictable. After the sling procedure, she has correction of SUI, but urge symptoms persist.




Discussion of Case


Mixed urinary incontinence (MUI) refers to the complaint of involuntary leakage associated with urgency and with increases in intra-abdominal pressure such as coughing and straining. More recent data and expert consensus support the selective use of anti-incontinence procedures to correct SUI in patients with mixed symptoms who have a significant SUI component (Dmochowski et al., 2010). Both retropubic and transobturator tape (TOT) midurethral slings (MUS) have been shown to have excellent cure rates of 85% to 97% for the stress component (Jain et al., 2011). Researchers have also analyzed the efficacy of MUS in treating the urge components and which factors predict better or worse outcomes. Several studies have compared efficacy of retropubic and TOT slings for the treatment of women with MUI. Gamble et al. (2008) reported 305 women with objective evidence of SUI and detrusor overactivity undergoing TOT, tension-free vaginal tape (TVT), SPARC (American Medical Systems, Minneapolis, MN), or biologic bladder neck sling procedures. Primary outcome was persistent detrusor overactivity at 3 months. Resolution of detrusor overactivity differed significantly between the groups with the best results after TOT slings (47%) followed by retropubic slings (37%) and bladder neck slings (14%) (P > .001). Subjective cure of urge incontinence was seen in 44% of the whole group. In contrast, a similar study by Botros et al. (2007) found no difference in resolution of detrusor overactivity 3 months after retropubic versus TOT slings. A large observational cohort by Lee et al. (2010b) studied 514 women with MUI and 754 women with SUI and urge symptoms (but no urge incontinence) who were treated with retropubic or TOT slings. At a mean follow-up of 50 months, there was resolution of urge incontinence in 67.7% and urge symptoms in 59.7%. Preoperative detrusor overactivity, which was objectively demonstrated on urodynamics testing, was a risk factor for persistent urge incontinence and urgency.


Some studies with longer follow-up have demonstrated less encouraging outcomes. Kulseng-Hanssen et al. (2008) reported on a series of 1113 patients with MUI at 38 months after TVT and found a subjective cure rate of 53.8%. When only patients with predominantly urge incontinence were considered, subjective cure rate was 38.4%; however, patient satisfaction was still 60%.


Patients with complaints of MUI are extremely challenging when contemplating surgical correction. At the present time, based on available literature, the authors prefer whenever possible to manage these patients with a TOT sling in contrast to a retropubic or single-incision sling. Patients need to be counseled and to understand fully that the outcome of the urge component of their leakage is unpredictable, and there is a possibility that it could persist or worsen after sling placement.




Case 2: Recurrent Stress Urinary Incontinence After Two Previous Unsuccessful Synthetic Midurethral Sling Procedures



image (Video 14-1)


A 38-year-old woman presents with dyspareunia and severe recurrent stress incontinence; she has received two previous synthetic MUS and an anterior trocar-based mesh kit for a cystocele. There is no evidence of mesh erosion into the anterior vaginal wall; however, significant pain is elicited on palpation of the middle of the anterior vaginal wall secondary to mesh shrinkage. Urodynamics confirms severe SUI secondary to intrinsic sphincter deficiency, and examination of the anterior vaginal wall notes minimal urethral mobility (Q-tip strain angle of 15 degrees). Cystoscopy is negative for any mesh erosion. The patient gives consent for excision of previously placed suburethral portions of the synthetic slings, with vaginal urethrolysis (in the hope of creating more urethral mobility) excision of mesh from the anterior vaginal wall, and placement of a rectus fascia pubovaginal sling under the proximal urethra.


During the removal of one of the synthetic slings, it became apparent that sling material was in the wall of the urethra. Sharp excision of the polypropylene from the wall of the urethra was required resulting in a urethrotomy; this was repaired in two layers ensuring that the lumen of the urethra was not constricted. Because there was an appropriate blood supply, no vascular pedicle was thought to be needed, and we proceeded with placement of the rectus fascia sling. Postoperatively, the patient had complete resolution of SUI and vaginal pain, but she developed de novo urgency and urge incontinence, which required antimuscarinic therapy and pelvic floor rehabilitation.



Discussion of Case


Evaluation and treatment of women with persistent or recurrent SUI after a previous incontinence procedure depend on the nature of the original treatment; the presence or absence of associated urgency, frequency, and voiding dysfunction; and the current state of the surrounding tissue. Approximately 10% to 20% of women undergoing a sling procedure have persistent or recurrent SUI. Objective data to guide the appropriate choice of a secondary surgical procedure are limited. Generally, women with persistent or recurrent SUI should undergo a thorough evaluation, which almost always includes urodynamics studies and endoscopic assessment. The operative notes from the original surgery should be obtained if at possible. Although there are no good studies currently evaluating the role of a repeat synthetic MUS after a failed synthetic MUS, the overall cure rates for repeat MUS have been shown to be lower than the cure rates for primary surgery. In uncontrolled case series, both retropubic and transobturator MUS have been shown to be effective salvage procedures at least in the short term. One large retrospective series suggested that retropubic MUS have a higher success rate than TOT MUS for patients with recurrent SUI. The authors have preferred to use retropubic MUS in patients who have failed TOT MUS. In patients who have failed single-incision MUS, TOT or retropubic MUS may be used. Sabaddel et al. reported good results with the use of retropubic TVT for recurrent SUI after failed TOT with overall cure and improvement rates of 86.4% at 12 months and 75% at 36 months.


In patients who have failed retropubic MUS, a repeat retropubic MUS and traditional pubovaginal sling are acceptable options. Although data are limited, the authors have also found retropubic MUS to be successful in patients with failed colposuspension with decreased bladder neck mobility. If the urethra is hypermobile, TOT MUS would also be a viable option. Finally, in patients who have a fixed urethra, are unstable, or are unwilling to undergo repeat surgery, paraurethral bulking can be considered (see Chapter 10).




Case 3: Stress Incontinence in Conjunction with Symptomatic Pelvic Organ Prolapse

Related posts:

Bladder Augmentation Single-Incision Synthetic Midurethral Slings Retropubic Synthetic Midurethral Slings Surgical Anatomy of the Anterior Vaginal Wall, Retropubic Space, and Inner Groin Surgical Management of Voiding Dysfunction and Retention After Stress Incontinence Surgery Sacral Neuromodulation

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May 29, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Mixed and Recurrent Incontinence, Incontinence in Patients with Pelvic Organ Prolapse, and How Best to Avoid and Manage Complications: Case Discussions

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