Download Antalya-OAB-Surgery-Repaired

Overactive Bladder Symptoms (OAB)
cured by surgery
Cerrahi ile tedavi edilen aşırı aktif mesane semptomlar
A. Gunnemann
13. Ulusal Jinekoloji ve Obstetrik Kongresi
Belek/Antalya 12.05.2015
OLD DEFINITION
OAB symptoms:
- associated with the unstable bladder (
bladder contracting involuntarily during
the filling phase of a cystometrogram)
- detrusor hyperreflexia (if neurological
disease was present)
- detrusor instability (if the cause was
unknown or non-neurogenic).
CURRENT DEFINITION:
The overactive bladder syndrome (OAB) is defined
as urinary urgency, usually with urinary frequency
and nocturia, with or without urgency urinary
incontinence
International Continence Society (ICS) Standardisation of Terminology of Lower Urinary Tract
Symptoms and the joint ICS and International Urogynecological Association (IUGA) report on
the Terminology for Female Pelvic Floor Dysfunction
Treatment of neurogenic
urgency incontinence:
- Neuromodulation
- percutaneous tibial nerve
stimulation (PTNS)
- bladder augmentation
- Botulinium toxin injection
4
Treatment of non neurogenic Urgency Incontinence
(ICS):
antimuscarinic and anticholinergic drugs:
darifenacin, fesoterodine, oxybutynin, propiverine,
solifenacin, tolterodine, trospium and Beta3 agonists
None of the drugs are an ideal first-line treatment for
all OAB/DO patients:
treatment individualisation
patient’s comorbidities, concomitant medications and
pharmacologic profiles of different drugs.
BUT large metanalyses show clearly that the drugs
provide a significant benefit
Anticholinergic therapy: do the patients
take the pills prescribed
Jundt et al. 2011
After 12 months at least (N = 132)
38 % (N = 51) take the drug furthermore
N = 23 (17 %) continent, much improved and satisfied
N = 17 only few improved und unsatisfied
N = 11 not improved
62 % (N = 81) withdraw the drug
For different reasons,
stress and urge derive mainly from laxity
in the vagina or its supporting ligaments,
a result of altered collagen/elastin
www.integraltheory.org
P. Petros, U. Ulmsten 1990
Connective tissue at the pelvic floor
which can be loose
and surgically be repaired
(Petros)
Anterior Zone
(Meatus urethrae to bladder neck)
pubourethral ligament
hammock
extraurethral ligament
Middle Zone
(bladder neck to anterior cervix)
Arcus tendineus fasciae pelvis
pubocervical fascia
cervical ring
Posterior Zone
(posterior cervix to anal canal)
uterosacral ligament
rectovaginal fascia
perineal body
Tethered vagina:
contracted vaginal scar at bladder neck
Trampolinanalogy
The stretch receptors “N”
Transient Receptor Potential channels (TRPs)
in the urothelium
“TRPs” are sensitive to pressure.
They release chemicals such NO (nitrous oxide) and ATP which stimulate
afferent nerve fibres (NF), smooth muscle cells (SMC) and interstitial cells (ICC).
From Everaerts et al 2008
STRAINING
The anterior vaginal wall acts like a trampoline beneath the bladder
DYNAMIC ANATOMY
OF
STRESS URINARY CONTINENCE
the key role
of the pubourethral ligament
Nocturia causation- patient lying supine in bed
Empty bladder-dark green enclosed by red broken lines
A weak uterosacral ligament ( USL)
cannot support the filling bladder
which is stretched downward
by gravity ‘G’.
Stretch receptors “N”
Send afferent impulses
to cortex
USL
perceived as urgency
which wakens the patient
(nocturia).
G
De Boer et al. 2010
Prevalence of OAB Symptoms in Relation to Symptoms and Signs of POP
In Community-Based Studies
(Boer et al. 2010)
Community-based studies
N
Frequency of OAB Symptoms in women
with POP
without POP
RR (POP/no POP)
Tegerstedt et al. 2005
5.489
22,5 % (454) 2,9 % (5.035)
5,8
Lawrence et al. 2008
4.103
36,8 % (239) 9,1 % (3.799)
4,0
228
52,0 % (223) 25,0 % (44)
2,1
34,4 % (96)
2,1
Miedel et al. 2008
Fritel et al. 2009
2.640
16,2 % (2.544)
Prevalence of OAB Symptoms Before and After POP Surgery without Concomitant Incontincene Surgery
(de Boer et al. 2010)
Author:
N
Follow-up
months
Frequency of OAB symptoms
preoperative postoperative RR (pre/post)
Stanton et al. 1991
Jörgensen et al. 1987
Chaikin et al. 2000
Nguyen, Bhatia 2001
Weber et al. 2001
Sivaslioglu et al. 2005
Farnsworth 2004
Farnsworth 2004
Milani et al. 2005
Salvatore et al. 2005
Brubaker et al. 2006
Digesu et al. 2007
Natale et al. 2007
Basu et al. 2009
Li Marzi et al. 2006
Miedel et al. 2008
Natale et al. 2008
Siviasloglu et al. 2009
44
16
10
38
82
30
59
24
32
64
165
93
27
49
51
111
272
85
24
37
47
27,3 %
87,5 %
40 %
100 %
53,3 %
53,3 %
41 %
62,5 %
50 %
75,3 %
28,1 %
62,3 %
44,4 %
100 %
37,2 %
27,9 %
46,7 %
24,7 %
23
16
18,4
19,4
17
93
3
12
9
2,5
17,7
12
60
12
4,2 %
63 %
20 %
36,8 %
13,3 %
13,3 %
15,5 %
21,7 %
40 %
16,3 %
11,9 %
17,2 %
14,8 %
46,7 %
5,8 %
18 %
22,1 %
2,4 %
6,5
1,4
2,0
2,7
7,0
4,0
2,6
2,9
1,3
4,6
2,4
3,7
3,0
2,1
6,4
1,6
2,1
10,3
Petros 2009
Tissue Fixation System
Symptomatic Results (n=71) - Time 9 months
Stress incontinence
n=35
(87%)
Faecal incontinence
n= 23
(87%)
Abnormal emptying
n=53
(73%)
Urge incontinence (>2/D) n=36
Nocturia (>2/N)
N=47
Pelvic pain
n=46
(78%)
(83%)
(86%)
Uterovaginal Prolapse
(97%)
(n=67)
Petros 2004
Surgical treatment of mixed and urge incontincen in women
Jäger W et al. 2012
(prolapse stage 4: N = 0 stage 3: N = 2: stage 2: N = 2, stage1: N 129)
Elevate anterior/apikal
N = 142
Fixation by minianchor with less tissu trauma
Monofil, makroporous, lightweight (24,2 g/m2) Mesh (Intelpro lite, AMS)
Elevate anterior/apikal – Symptomscores preop. and after 24 months.
Variable
PISQ
Baseline (N)
32 (N=59)
Follow-up (N)
36 (N=56)
p-Value
< 0,001
UIQ
27 (N=142)
4,7 (N=124)
< 0,001
CRAIQ
12,4 (N=135)
2,6 (N=124)
< 0,001
POPIQ
19,8 (N=141)
1,8 (N=124)
< 0,001
PFIQ
58,6 (N=139)
9,1 (N=124)
< 0,001
UDI (obstr./discomfort)
35,2 (N=14)
6,5 (N=124)
< 0,001
UDI (irritative)
27,7 (N=142)
8,1 (N=124)
< 0,001
UDI (stress)
23,9 (N=142)
5,8 (N=124)
< 0,001
POPDI (general)
43,3 (N=142)
CRADI (obstructive)
29,8 (N=142)
CRADI (Incontinence) 21,8 (N=142)
CRADI (Pain/Irritation)
5,8 (N=124)
9,6 (N=124)
9,1 (N=124)
21,0 (N=142)
< 0,001
< 0,001
< 0,001
7,5 (N=124)
< 0,001
Elevate posterior/apikal – Symptomscores preop. and after 24 months
Variable
Präop. (N)
Follow-up (N) p-Value
PISQ
33 (N=57)
36 (N=49)
< 0,001
UIQ
28 (N=137)
8,5 (N=112)
< 0,001
CRAIQ
18,3 (N=135)
5,6 (N=112)
< 0,001
POPIQ
19,4 (N=136)
4,6 (N=112)
< 0,001
PFIQ
65,4 (N=135)
18,8 (N=112)
< 0,001
UDI
98,5 (N=139)
29,4 (N=113)
< 0,001
POPDI
123,8 (N=139) 37,6 (N=113)
< 0,001
CRADI
111,2 (N=139) 42,7 (N=112)
< 0,001
PFDI-question 18
Do you usually feel a strong urge to void your bladder ?
35,2 %
P < 0,01
70,0 %
P < 0,01
70,0 %
P < 0,01
71,3 %
Nocturia cure rates after
reconstruction of apical descent
Author
Patients
with Nocturia
Follow-up
N
Patients cured
N
%
Petros 2008
9-21 m
47
39
83 %
< 0,01
Inoue 2012
3-57 m
88
61
69 %
< 0,01
Sivasioglu 2011
10-22 m
38
23
61 %
< 0,05
42
34
81 %
< 0,01
Farnsworth 2003 12 m
p
Pessary treatment for pelvic organ prolapse and health-related quality of life: a review
Lamers BHC, Broekman BMW, Milani AL.
Int Urogynecol J 2011;22:637-644
Cystocele
Folie - 26 -
simulated operation by inserting a tampon (temporary pessary)
Folie - 27 -
Summary
• Urge incontinence can be caused by pelvic organ
prolapse
• Surgery can cure female urge incontinence
in up to 80 % by careful anatomical pelvic floor
reconstruction
• Special case: „Tethered vagina Syndrom“
PFDI Question 17: „do you urinate usually very often ?“
31,6 %
P < 0,01
71,7 %
P < 0,01
72,0 %
P < 0,01
72,7 %
PFDI question 19
Do you loose urine while have a strong feeling of urgency?
42,7 %
P < 0,01
74,1 %
P < 0,01
75,7 %
P < 0,01
75,6 %
PFDI question 27
Does urgency wake you up during the night?
31,0 %
P < 0,01
58,3 %
P < 0,01
57,4 %
P < 0,01
55,8 %