SAUGA NEWSLETTER March 2019
Welcome
   
Message from the President:

Dear Colleagues

Welcome to our 2019 quarterly newsletter. In this issue, we publish three articles on stress urinary incontinence (SUI) from basics to surgical intervention. Thank you to Prof Andreas Chrysostomou and team for this effort. No doubt, the use of mesh for the management of SUI is once again in the public spotlight prompted by life-changing mesh related complications. As a result, there has been a renewed interest on the use of bulking agents for SUI. We look forward to the results of the first head-to-head randomized clinical trial on TVT vs Bulkamid at SAUGA Congress in August by the investigator himself, Professor Tomi Mikkola, Associate Professor of Urogynecology, Helsinki University, Finland. Pease SAVE THE DATE-8-10 Aug 2019.

Finally, a kind reminder to renew your SAUGA membership and register for the upcoming SAUGA Congress by visiting www.sauga.org.za

“I fear not the man who has practiced 10,000 kicks once, but I fear the man who has practiced one kick 10,000 times”- Bruce Lee

Yours Truly
Prof Zeelha Abdool
SAUGA President

Message from the Editor:

From the desk of the Editor: Peter de Jong

As our winter draws nearer, I urge you to dress warmly and take your influenza vaccines. I would like to take this opportunity to commend the memory of the late Monty Brink to your thoughts. He was an accomplished and skilled Urogynae surgeon and one of the very first to do laparoscopic Burch procedures in this country. Later as newer techniques become available, he became adroit at a number of novel techniques, and was an excellent surgeon.

Monty was a man of great empathy and character, an accomplished sportsman, and a wonderful all-rounder.

Our hearts go out to his friends, family and patients. He will be sorely missed, having been taken from this earth at the peak of his powers.

Age will not wither him, nor the years condemn him to obscurity. We will all remember his friendly, engaging smile and ready laugh.

Farewell to a wonderful colleague.

   
Prof A Chrysostomou MD, FCOG (SA), MMed (Wits)

Head: Urogynaecology and Endoscopy Unit
Department of Obstetrics and Gynaecology
Charlotte Maxeke Johannesburg Academic Hospital and
The University of the Witwatersrand
e-mail: andreas.chrysostomou@wits.ac.za
cell: 0833244122
   
THE PATHOPHYSIOLOGY OF FEMALE STRESS URINARY INCONTINENCE – CLINICAL IMPLICATIONS


Introduction
Stress Urinary incontinence (SUI)is defined as the involuntary leakage of urine on effort, exertion, sneezing, or coughing. It is an emotionally and physically devastating condition, and can adversely affect a woman’s quality of life. The effective management of SUI requires knowledge of the pathophysiological mechanisms of the disorder. The continence control system can be divided anatomically into two parts: the urethral support system and the sphincter closure system.

The urethral support system
The urethral support system consists of all the structures that provide a supportive layer upon which the bladder and urethra rest. The major components of this structure include the anterior vagina wall, the endopelvic fascia, the arcus tendineus fasciae pelvis (ATFP), and the levator ani muscles. Condensation of the endopelvic fascia gives rise to uterosacral and cardinal ligaments that provide Level I support to the pelvic organs, encircling the cervix, and continuing anteriorly as a pubocervical fascia. This fascia is extended from one to the other ATFP like a hammock where the bladder and the urethra rest, thus offering Level II support (Fig1).

Fig. 1 :Lateral view shows the components of the urethral support system. Note how the levator ani muscles support the rectum, vagina, and urethrovesical neck. Also note how the endopelvic fascia beside the urethra attaches to the levator ani muscle. A contraction of the muscle would lead to elevation of the urethrovesical neck.

The ATFP is attached to the pubic bone ventrally and to the ischial spine dorsally. Although welldefined near its origin as a fibrous band at the pubic bone, the ATFP becomes a broad aponeurotic structure as it passes dorsally to the ischial spine. It therefore appears as a sheet of fascia as it fuses with the endopelvic fascia, where it merges with the levator ani muscles (Fig. 2).

Fig. 2 : White arrows show the arcus tendineus levator ani; the black arrows show the arcus tendineus fascia pelvis.


Functionally, the levator ani muscles and the endopelvic fascia serve an interactive role in maintaining continence and pelvic support. Normal function of the urethral support system requires the contraction of the levator ani muscle, which supports the urethra through the endopelvic fascia. Isolated breaks into the endopelvic fascia may not be associated with SUI if the levatori ani muscles are intact. The levator ani muscles relieve tension applied on the endopelvic fascia during effort, and contraction enhances urethral closure and continence. This resistance of the supportive layer to the dorsocaudal displacement of the urethra is known as “stiffness”. In the presence of adequate stiffness, an increase in the intra-abdominal pressure results in the compression of the anterior wall against the posterior wall of the urethra, thereby aiding the closure of the urethral lumen and the prevention of leakage Bearing this in mind, SUI may occur if there are breaks in the continuity of the endopelvic fascia, or if the levator ani muscle were to be damaged, as the supportive layer under the urethra would likely be less stiff providing less resistance to closure of the urethral lumen, thereby increasing the likelihood of SUI. Additionally, the constant tone maintained by the pelvic muscles relieves the tension placed upon the endopelvic fascia. If the innervation of the levator ani muscle is damaged (such as can occur during childbirth), the denervated muscles would undergo atrophy, thereby leaving the responsibility of pelvic organ support upon the endopelvic fascia alone. Over time, these ligaments would exhibit viscoelastic behaviour, gradually stretching under the constant load, leading to the development of prolapse and SUI (Fig. 3). Fig. 3: The analogy of the boat (pelvic organs) in the port, where the sea represents the levator ani muscles and the ropes holding the boat are the ligaments (A). Once the water is drained the ligaments cannot support it and the boat sinks (B).



The sphincteric closure system
There are several important clinical correlates of urethral muscular anatomy. Perhaps the most important of these is the realisation that stress incontinence is caused by problems with the urethral sphincter mechanism as well as with urethral support. Essential anatomic elements of continence include proper mucosal apposition, constant urethral tone, and maintenance of the bladder neck/proximal urethra in the retropubic position. Functionally, the urethral muscles maintain continence in various ways. The U-shaped loop of the detrusor smooth muscle surrounds the proximal urethra, favouring its closure by constricting the lumen. The mucosa and submucosa of the urethra contain an extensive submucosal venous plexus that forms a cushion to keep the urethra closed at rest (Fig. 4).

Fig. 4: Anatomy of the urethra shown in longitudinal section. The sphincteric closure of the urethra is normally provided by the urethral striated muscles, urethral smooth muscle, and vascular elements within the submucosa (Fig. 5). Each is thought to contribute equally to the resting urethral closure pressure.


Two layers of smooth muscle, an inner longitudinal and outer circular layer, surround the mucosa. The longitudinal layer serves primarily to shorten the urethra during micturition, but the circular layer adds further to the urethral tone. The striated urethral sphincter (also termed the urogenital sphincter) surrounds the inner layers and is composed of three elements located in the mid part of the urethra: the rhabdosphincter, the compressor urethrae, and the urethra-vaginal sphincter. These striated muscles are under voluntary control but are subject to reflex arcs, with the three portions acting as a functional unit. This sphincter contributes to the resting tone of the urethra as well as to continence during stress, acting primarily as a back-up mechanism in those with hypermobility of the urethra-vesical junction (UVJ).Thus, the presence of urethral hypermobility does not necessarily imply SUI. The goal of sling surgery may not only provide a back-stop mechanism to support the UVJ but also in some cases, to create some degree of urethral coaptation or compression, keeping incontinent women dry during effort.

Conclusion
The continence control system is a combination of synergic action of levator ani muscles, endopelvic fascia, and the urethral sphincteric closure system. All this contributes to maintaining continence. Understanding the pathophysiology of continence on the anatomical level will help us to identify specific defects, allowing us to provide individualised treatment for the incontinent patient.

  
THE MANAGEMENT OF STRESS URINARY INCONTINENCE USING MIDURETHRAL SLINGS (MUS)

Introduction
According to ICS two major pathophysiologic theories have emerged over the past fifty years, Urethra hypermobility and intrinsic sphincter deficiency (ISD), which have influenced the development and adoption of surgical techniques. These two entities are not dichotomous but often coexist. MUS, in treating both entities, is an accepted procedure with proven efficacy and safety in the majority of patients with moderate to severe SUI, when used by an experienced and appropriately trained surgeon.

The management of SUI is dominated by mid urethral slings (MUS). The Tension-free Vaginal Tape (TVT) is a standard, minimally invasive procedure used to treat SUI, introduced by Ulmsten in 1995.In spite of its proven efficacy of subjective and objective SUI cure of 90% at the 11 and 17-years follow up, TVT has been found to be associated with intra- and post-operative complications such as bowel, urethral, bladder perforations, major blood vessel injuries and deaths as well as post-operative voiding difficulties, de novo urgency and urge incontinence (UI). These complications are related to entry into the retro-pubic space and to the “u” shape of the tape once inserted, leading to more contact with the urethra.

In 2001, Delorme described the Transobturator Tape (TOT) as a mid-urethral sling for the surgical treatment of SUI. This minimally invasive procedure, termed “outside-in” in which the tape is inserted in an almost horizontal plane underneath the middle of the urethra, between the two obturator foramina- has almost replaced the TVT. The TOT technique has been safer, due to avoidance of entry into the retro-pubic space. A modified technique (“inside-out”) of TVT-O(Tension free Vaginal Tape-Obturator) was introduced by de Leval in 2003. Although cystoscopy is mandatory with a TVT, it is not always recommended with the TOT, and TVT-O technique. Worldwide the surgical management of female SUI using MUS is dominated by the TVT, TVT-O and the TOT. Since 2006 in our Urogynaecology unit at CMJAH, we’re managing SUI with TOT outside-in.

Discussion:
Objective bed side investigations includes a positive cough test, performed in lithotomy or standing position with a comfortable filled bladder, absence of abdominal mass or genital prolapse. Infection should be excluded using urine dipsticks and the residual volume should be less than 100 ml. Chronic illnesses should be ruled out from the history, as well as medications that may have urinary adverse effects (diuretics, antidepressants, anticholinergics, antipsychotics). Routine urodynamic studies (UDS) are not performed to confirm the diagnosis of SUI in patients with demonstrable SUI prior to surgery. Although this may be considered by some as a weakness , there is evidence available to demonstrate that the cough test is a useful and reliable tool in the diagnosis of SUI, especially in countries with limited resources and in absence of symptoms indicating an Overactive Bladder (OAB). It is recommended that women with a clearly defined clinical diagnosis of SUI do not need routine UDS prior to surgical intervention. We limit UDS to the patients with the history of OAB symptoms and those with RV > 100ml in absence of a cystocele. This is supported by the literature that shows that there is little reason to delay surgery prior to treatment. Important issues also include cost, discomfort and lack of reproducibility. The success rates in treating SUI, reported in the literature for the TVT, TVT-O and TOT ranges between 90-97%. The complication are higher in TVT especially bladder injury and voiding difficulties. This is due to the passage of the Tunnellers through the retropubic space. There is a decreased risk of intra-operative complications with TOT as compared to TVT, particularly bladder perforation.

Abdel-Fatah et al in 2006 reported 4 cases of urethral and bladder perforation in their series of 389 cases comparing TOT to TVT-O. He stated that all occurred in TOT “outside in” group, and no cases of bladder perforation were reported in the TVT-O “inside out” group. However, three of the perforations occurred during the dissections following vaginal incision, and only one bladder perforation during the insertion of the tunneller. If the correct technique is applied, the risk of bladder perforation with the tunneller is minimal. Bladder injury during the insertion of the tunneller as seen in TVT should be distinguished from the bladder injuries during the creation of the tunnels as seen in Transobturator techniques (TOT, TVT – O). It is evident from the literature that both Transobturator tape techniques are associated with lower risks of bladder perforation as compared to retro-pubic techniques.

Because bladder perforation is one of the most common intraoperative complications of retro-pubic mid-urethral slings, cystoscopy is mandatory, whereas the use of cystoscopy with the Transobturator approach is not always recommended. Cystoscopy can be considered in women who have concomitant vaginal surgery or where the TOT procedure is considered difficult. In case of bladder perforation during vaginal dissections for the creation of the tunnels we recommend bladder repair in two layers and the procedure be completed. Post-operative urethral catheterization should be left in-situ for 10 days, followed by VCU.
Sling failure can be managed by reinserting a new sling, or by administering bulking agents. In the cases of sling erosion we recommend excision of the exposed portion, if local application of estrogen vaginal cream for six weeks fails. Sling erosions may be secondary to surgical technique and may represent an inadequate dissection below the pubocervical fascia, or undiagnosed vaginal perforation during insertion of the tunneller in cases of TOT outside-in. We recommend the lateral vagina fornix to be checked after insertion of the tunneller. If perforation is diagnosed we advise the tunneller to be removed and reinserted.
Urinary retention following TOT placement has been reported in the literature to be between 1, 5 to 15%. In our setting we report no cases of urinary retention following TOT procedure for SUI. This may be attributed to the fact that in all cases the catheter was clamped on the first postoperative day, and removed on the second day before discharge. This not only allows bladder retraining but may also decrease tension of the sling in the immediate postoperative period. Post-operative groin or thigh complications with TOT were found in other studies, none were found in the cases performed by our unit. Groin or thigh complications found to be uncommon with TOT outside-in insertion during follow up in our setting. Groin or thigh pain has been found to be more common with TVT-O inside-out procedures with a reported incidence of 16%-17%. A sub-analysis performed by Cheng Yu Long found that TVT-O appeared to be more painful and the possible cause was that the exit point of the TVT-O needle is closer to the adductor muscle and the obturator neurovascular bundle compared with the outside-in TOT. Cadaver studies show that tapes inserted via the Transobturator route using an ‘outside- in’ technique have a lower risk of pudendal neurovascular bundle injury as the tape may be placed further from the obturator canal and closer to the ischiopubic ramus . Tapes placed with the “inside out” technique were found further from the ischiopubic ramus and closer to the obturator canal.
The literature suggests that patients may experience a deterioration of their sexual function following the mid-urethral sling procedure. This can occur as a result of the development of dyspareunia after the surgery or due to decreased blood supply to the clitoris. De novo dyspareunia might be caused by the position of the tape, as the use of tape may result in vaginal narrowing, paraurethral banding or erosion. The effect of clitoral blood supply after the TVT and TOT procedure was investigated by Caruso et. al, with the aid of colour Doppler ultrasonography. It was concluded that blood flow to the clitoris was negatively affected by TVT but not by the TOT. Thus, the TOT was proved to be an anatomically safer approach, which does not impair the sexual function of the patient. The literature also states that the quality of life is much improved after the treatment of SUI with MUS and often correlates with the objective cure rates.

A poorly functioning urethra can contribute to intrinsic sphincter deficiency, which is a severe form of SUI. In this situation the patient leaks with a minimal effort. A Substantial decrease in urethral closure pressure is seen with age. The cause of ISD may be age related urethral mucosa atrophy but it can also occur in estrogen deficient patients as a result of multiple operations or following radiation. The above factors can impair smooth muscle function and can prevent normal apposition of urethral mucosa. ISD urodynamically is defined as the Vulsalva leak- point pressure (VLPP) of < 60cmH2O or maximum urethral closure pressure (MUCP) of <20 cm H2O. ISD was a principal cause of failure for Burch colposuspension which dominated the management of SUI prior to the MUS era. The surgical management of ISD is mainly with mid-urethral slings. In an editorial by Swift in 2013(Intrinsic Sphincter Deficiency: what is it and does it matter anymore) he stated that patients with a mobile urethra (point Aa> than-1cm in POP-Q) benefit from both TOT and TVT. He also mentioned that the risk of failure is higher in TOT as compared to TVT in patients with a fixed or immobile urethra.

SUMMARY
There are enough high quality evidence supporting the use of the MUS in the management of SUI. There are greater than 2,000 publications in the scientific literature describing the MUS in the treatment of SUI, which consistently demonstrates its clinical effectiveness, as well as physician and patient satisfaction. No other surgical treatment for SUI before or since has been subject to such extensive investigation. The FDA supports the multi-incision slings because the safety and their effectiveness are well established in clinical trials. Multi-incisional slings in all studies were found to be superior to single incision slings. Long term outcomes of the single incision slings studies are needed.

THE MANAGEMENT OF STRESS URINARY INCONTINENCE USING SINGLE- INCISION SLINGS

Introduction

Stress urinary incontinence (SUI) is the most commonly diagnosed subtype of urinary incontinence (UI) in adult women. Data suggest that of all women with urinary leakage, around 50% will exhibit pure SUI, with 30% experiencing mixed incontinence. It is estimated to affect up to one-third of women older than 18 years, with a median age of 45 years. SUI is usually the result of the failure of the urethral support system or weakening of the urethral sphincter muscle at the base of the bladder, which maintains continence. The management of SUI has been dominated in the last twenty tears by mid urethral slings (MUS), with subjective and objective SUI cure rates of 80-90%. However, they have been shown to have occasional intra-operative complications, such as bowel, urethral, and/or bladder perforations, major vessel injuries, as well as post-operative thigh/ groin pain, voiding difficulties, de novo urgency and urge incontinence (UI). In an effort to maintain efficacy while eliminating some of the side effects, a new generation of slings has been developed, called “single-incision slings” or “mini-slings”. Single-incision slings were introduced as a safe procedure of treating SUI based on the fact that it avoids entry into the obturator foramina, as in cases of transobturator tape (TOT), and tension-free vaginal tape – obturator (TVT-O) or into the retropubic space as has happened with tension-free vaginal tape (TVT).

Jeffery S, et al. (2010) performed a systematic review comparing success rates of minislings to the traditional MUS, and found that the success rates with different types of mini slings were 70-80%, which is less than that of traditional slings. Operation times compared to traditional slings were shorter, bladder perforations less common (0.45% as compared to 3-4% recorded for TVT or TOT). Additionally, de novo urgency was found in 6.6%, and 0.65% reported inguinal extensor complaints. Abdel-Fattah et al. performed a meta-analysis of effectiveness and complications of mini slings versus standard MUS in surgical management of SUI, and deduced that the success rates for mini-slings were lower than the traditional slings

In a Cochrane review in 2014 entitled ”Single-incision sling operations for urinary incontinence in women”, Nambiar identified 31 trials involving 3290 women, all of which compared a type of a single-incision versus a type of MUS. Transobturator tape (TOT) and tension free vaginal tape (TVT) were compared to: TVT-secur, Mini Arc, Adjust, and needleless slings, among others. Despite the fact that mini-slings were found to be quicker, no clear evidence emerged that claimed they are cost effective or may cause less postoperative pain. Single incision slings were shown to provide poorer control of incontinence. Higher risk of de novo urgency as compared to TVT and more complications (mesh exposure/erosion urethra/blood loss as compared to TOT) were also found.

Conclusion:

More trials are needed to determine whether mini-slings are in fact as good as the standard MUS


SAUGA NEWSLETTER March 2019