AUA/SUFU 2017- Surgical Tx of Female SUI

Question 1

In the initial evaluation of patients with stress urinary incontinence desiring to undergo surgical intervention, physicians should include the following components:

Answer 1

1- History, including assessment of bother
2- Physical examination, including a pelvic examination
3- Objective demonstration of stress urinary incontinence with a comfortably full bladder (any method)
4- Assessment of post-void residual urine (any method)
5- Urinalysis

Question 2

Physicians should perform additional evaluations in patients being considered for surgical intervention who have the following conditions

Answer 2

1- Inability to make definitive diagnosis based on symptoms and initial evaluation
2- Inability to demonstrate stress urinary incontinence
3- Known or suspected neurogenic lower urinary tract dysfunction
4- Abnormal urinalysis, such as unexplained hematuria or pyuria
5- Urgency-predominant mixed urinary incontinence
6- Elevated post-void residual per clinician judgment
7- High grade pelvic organ prolapse (POP-Q stage 3 or higher) if stress urinary incontinence not demonstrated with pelvic organ prolapse reduction
8- Evidence of significant voiding dysfunction

Question 3

Physicians may perform additional evaluations in patients with the following conditions:

Answer 3

 Concomitant overactive bladder symptoms
 Failure of prior anti-incontinence surgery
 Prior pelvic prolapse surgery

Question 4

In patients wishing to undergo treatment for stress urinary incontinence, the degree of bother that their symptoms are causing them should be considered in their decision for therapy.

Answer 4

True, makes sense

Question 5

In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence who wish to undergo treatment, physicians should counsel regarding the availability of the following treatment options:

Answer 5

• Observation
• Pelvic floor muscle training (± biofeedback)
• Other non-surgical options (e.g., continence pessary)
• Surgical intervention

Question 6

Physicians should counsel patients on potential complications specific to the treatment options.

Answer 6

True true

Question 7

Prior to selecting midurethral synthetic sling procedures for the surgical treatment of stress urinary incontinence in women, physicians must discuss the specific risks and benefits of mesh as well as the alternatives to a mesh sling.

Answer 7

right right right

Question 8

In patients with stress urinary incontinence or stress-predominant mixed urinary incontinence, physicians may offer the following non-surgical treatment options:

Answer 8

 Continence pessary
 Vaginal inserts
 Pelvic floor muscle exercises

Question 9

In index patients considering surgery for stress urinary incontinence, physicians may offer the following options:

Answer 9

1- mid urethral sling
2- Autologous fascia pubovaginal sling
3- Burch colposuspension
4- Bulking agents

Question 10

In index patients who select midurethral sling surgery, physicians may offer either the ……or……sling.

Answer 10

retropubic or transobturator midurethral

Question 11

Physicians may offer …….. to index patients undergoing midurethral sling surgery with the patient informed as to the immaturity of evidence regarding their efficacy and safety.

Answer 11

single-incision slings

Question 12

Physicians should …….. if the urethra is inadvertently injured at the time of planned midurethral sling procedure.

Answer 12

not place a mesh sling

Question 13

Physicians should not offer stem cell therapy for stress incontinent patients outside of investigative protocols.

Answer 13

True

Research only

Question 14

In patients with stress urinary incontinence and a fixed, immobile urethra (often referred to as ‘intrinsic sphincter deficiency’) who wish to undergo treatment, physicians should offer…..or….or………..

Answer 14

pubovaginal slings, retropubic midurethral slings, or urethral bulking agents

The Panel believes that in the case of a minimally mobile urethra, RMUS or PVS may a preferred option, and in the case of the non-mobile urethra, PVS may be the preferred option. AUS is an option too. This is just more like post RP SUI. Seems like fasical PVS is the preferred approach for these

Question 15

Physicians should not utilize a synthetic midurethral sling in patients undergoing concomitant urethral diverticulectomy, repair of urethrovaginal fistula, or urethral mesh excision and stress incontinence surgery.

Answer 15

True

Question 16

Physicians should strongly consider avoiding the use of mesh in patients undergoing stress incontinence surgery who are at risk for poor wound healing ( give 3 examples )

Answer 16

e.g., following radiation therapy, presence of significant scarring, poor tissue quality).
chronic steroid use, sjogern disease, SLE,

Question 17

In patients undergoing concomitant surgery for pelvic prolapse repair and stress urinary incontinence, physicians may perform …….

Answer 17

any of the incontinence procedures (e.g., midurethral sling, pubovaginal sling, Burch colposuspension).

Question 18

Physicians may offer patients with stress urinary incontinence and concomitant neurologic disease affecting lower urinary tract function (neurogenic bladder) surgical treatment of stress urinary incontinence after appropriate evaluation and counseling have been performed.

Answer 18

True

Question 19

Physicians may offer synthetic midurethral slings, in addition to other sling types, to the following patient populations after appropriate evaluation and counseling have been performed: (Expert Opinion)

Answer 19

 Patients planning to bear children
 Diabetes
 Obesity
 Geriatric

Question 20

Physicians or their designees should communicate with patients within the early postoperative period to assess if patients are having any significant voiding problems, pain, or other unanticipated events. If patients are experiencing any of these outcomes, they should be …….

Answer 20

seen and examined.

Question 21

Patients should be seen and examined by their physicians or designees within six months post-operatively. Patients with unfavorable outcomes may require additional follow-up

Answer 21

True

The subjective outcome of surgery as perceived by the patient should be assessed and documented.
 Patients should be asked about residual incontinence, ease of voiding/force of stream, recent urinary tract infection, pain, sexual function and new onset or worsened overactive bladder symptoms.
 A physical exam, including an examination of all surgical incision sites, should be performed to evaluatehealing, tenderness, mesh extrusion (in the case of synthetic slings), and any other potential abnormalities.
 A post-void residual should be obtained.

Question 22

Physicians should not perform cystoscopy in index patients for the evaluation of stress urinary incontinence unless there is a concern for urinary tract abnormalities.

Answer 22

TRUE

Question 23

Physicians may omit urodynamic testing for the index patient desiring treatment when ……

Answer 23

stress urinary incontinence is clearly demonstrated.

Question 24

Physicians may perform urodynamic testing in non-index patients.

Answer 24

True

Question 25

The index patient for this guideline, as in the previous iterations of the SUI guidelines, is an otherwise healthy female who is considering surgical therapy for the correction of pure stress and/or stress-predominant mixed urinary incontinence (MUI) who has not undergone previous SUI surgery. low grade POP is ok too.

Answer 25

Something to know

Question 26

Intrinsic sphincter deficiency (ISD) is often defined as a leak point pressure of less than ……. or a maximal urethral closure pressure of less than ……, often in the face of minimal urethral mobility.

Answer 26

60 cm H20

20 cm H20

Question 27

a woman with a positive clinical history had a…% chance of having SUI, whereas a woman with a negative clinical history had a …..% chance of having SU

Answer 27

74%

34%

Question 28

moderate strength evidence suggests that a positive Q-tip test has little value for diagnosis of SUI, is it recommended?

Answer 28

and this test cannot be recommended by the panel to diagnose SUI

Question 29

one may witness urine loss after an increase in intra-abdominal pressure has subsided. In this scenario, whats happening?

Answer 29

the incontinence may be, at least in part, due to an involuntary detrusor contraction (stress-induced detrusor overactivity).

Question 30

physicians should obtain the following details from the history, bladder diary, questionnaires, and/or pad testing.

Answer 30

1- Characterization of incontinence (stress, urgency, mixed, continuous, without sensory awareness)
2- Chronicity of symptoms
3- Frequency, bother, and severity of incontinence episodes
4- Patient’s expectations of treatment (patient-centered goals)
5- Pad or protection use
6- Concomitant urinary tract symptoms (e.g., urgency, frequency, nocturia, dysuria, hematuria, slow flow, hesitancy, incomplete emptying)
7- Concomitant pelvic symptoms (e.g., pelvic pain, pressure, bulging, dyspareunia)
8- Concomitant gastrointestinal symptoms (e.g., constipation, diarrhea, splinting to defecate)
9- Obstetric history (e.g., gravity, parity, method of delivery)
10- Previous treatments for incontinence (e.g., behavioral therapy, Kegel exercises/pelvic floor muscle training, pharmacotherapy, surgery)
11- Previous pelvic surgeries
12- Past medical history (e.g., hypertension, diabetes, history of pelvic radiation)
13- Current and past medications
14- Fluid, alcohol, and caffeine intake
15- Menopausal status
Additionally, the physical examination of the index or non-index patient should include the following components:
16- Focused abdominal examination
17- Evaluation of urethral mobility (any method)
18- Supine and/or standing stress test with comfortably full bladder
19- Assessment of pelvic prolapse (any method)
20- Assessment of vaginal atrophy/estrogenization status
21- Focused neurologic examination
Diagnostic evaluations that should be performed in the index or non-index patient include the following:
22- Urinalysis
23- PVR

Question 31

if patients elect surgical therapy, intraoperative cystoscopy should be performed with certain surgical procedures to …….

Answer 31

(e.g., mid-urethral or pubovaginal fascial slings)

confirm the integrity of the lower urinary tract and the absence of foreign body within the bladder or urethra

Question 32

The consensus of panel members is that cystoscopy should be performed in patients who have a history of prior anti-incontinence surgery or pelvic floor reconstruction, particularly if mesh or suture perforation is suspected. This suspicion may be based upon …….

Answer 32

new onset of lower urinary tract symptoms, hematuria, or recurrent UTI.

Question 33

What were the findings of the VALUE trial?

Answer 33

showed no difference in outcomes when adding UDS to office evaluation in 630 patients

Question 34

UDS can be performed in ( 8 indications)

Answer 34

 History of prior anti-incontinence surgery
 History of prior pelvic organ prolapse surgery
 Mismatch between subjective and objective measures
 Significant voiding dysfunction
 Significant urgency, UUI, overactive bladder (OAB)
 Elevated PVR per clinician judgment
 Unconfirmed SUI
 Neurogenic lower urinary tract dysfunction

Question 35

what are risks associated with SUI surgery>

Answer 35

bleeding, bladder injury, and urethral injury, as well as inherent risks of anesthesia, and of the procedure itself

abdominal, groin, vaginal, pain with sexual activity, thigh pain after sling placement, mesh exposure into vagina or into LUT

autologus fasical sling: thigh or abdominal hernia( depending of the harvest site( rectus fasica vs fascia lata). pain at the harvest site.

Question 36

the literature does not definitively suggest that MUS is more or less effective to alternative interventions, such as PVS or colposuspension.

Answer 36

TRUE

Question 37

Side effects of semi-synthetic midurethral slings?

Answer 37

Continued incontinence, voiding dysfunction, urinary retention, pain, dyspareunia
Vagina exposure, perforation into the lower urinary tract, greater risk of erosion with diabetes and smoking.

Question 38

what is another term to describe retropubic mid-urethral sling?

Answer 38

TVT

Question 39

what are two fascias you can use for autologous fascia pubovaginal sling?

Answer 39

Rectus fascia, fascia lata

Efforts to use other materials, such as porcine dermis and cadaveric fascia, as substitution for the autologous fascia have shown inferior results

Question 40

colposuspension is a viable approach for women with SUI who wish to avoid the morbidity of fascial harvest and also wish to avoid mesh, particularly if undergoing a simultaneous abdominal procedure, such as open or minimally invasive hysterectomy

Answer 40

True

Question 41

Do any of the surical approaches superior to another? autologus PVS, Burch or MUS

Answer 41

not really

Burch seems inferior to fasical sling but otherwise no significant difference

Question 42

is there a difference in outcomes bw in-to-out or out-to-in approach for TUMS

Answer 42

nope

Question 43

difference in bottom-up or top-down approach for RMUS?

Answer 43

nope

Question 44

A MUS may be considered in the non-index patient or in the patient with intrinsic sphincter deficiency

Answer 44

Correct

after appropriate evaluation and counseling. Also RMUS seem to work better for this cohort

Question 45

Should placement of MUS be deferred until after childbearing?

Answer 45

generally yes