Urogynae

Question 1

Mesh
- Issues

Answer 1

High reoperation rate
urinary incontinence
mesh exposure - 8-15%
high rates of bladder injury
SUI
Prolapse in other sites.

Mesh can now only be used under the therapeutic goods administration special access scheme - in a clinical trial

Much of the scientific evidence used to justify the use of early transvaginal meshes for prolapse isn’t applicable to the newer, lightweight transvaginal permanent meshes.

Question 2

Informed patient consent for mesh

Answer 2

Inform of withdrawal of mesh products for prolapse repair - limited robust data available on efficacy and safety

Woman who are at risk of recurrent vaginal prolapse and are suitable for mesh need to be in a clinical trial

Only operate on someone with symptoms (little data to recommend treating asymptomatic women)

Alternatives need to be discussed: pelvic floor muscle training, pessaries

Other alternative surgical treatments should be discussed: conventional native tissue repair, abdominal sacrocolpopexy

Risks: mesh exposure / erosion, vaginal scarring/ stricture, fistula formation, dyspareunia, unprovoked pain at rest - can occur many years later

Additional surgeries may be required for mesh complications. Complete removal sometimes is not possible

Question 3

Surgical training for mesh

Answer 3

Urogynae subspeciality or close attendance at hands on workshops multiple occasions and obserbation of theatre cases
Surgeons should keep themselves up to date in each kit
Regular surgeries
Cytoscopy
Knowledge fo complications

complications need to be logged under MEDSAFE

Question 4

Who would benefit from TV mesh implant?

Answer 4

Minimal data

those at increased risk of recurrent prolapse - obese, young, chronically raised abdominal pressure (asthma, constipation), stage 3-4 prolapse

Question 5

What are the three types of pessaries

Answer 5

Support: ring / gehrung
Space occupying (stages III-IV, not usually used if sexually active): gelhorn, shelf, donut cube (needs to be removed every day)
Incontinence with modification: contiform

Question 6

Advantages and disadvantages of pessaries

Answer 6

Advantages: high levels patient satisfaction, avoids surgery, cheap

Disadvantages: vaginal discharge, ulcerations (vesicovaginal, rectovaginal fistulae), embedded, expulsion, discomfort

Review 1/12 to ensure happy with it and then review annually if self management (can take out herself) or 6 monthly if supportive pessary, 3-4 month if occlusive pessary

Question 7

Surgical options for uterine prolapse

Answer 7

Vaginal hysterectomy

Abdominal sacrohysteropexy

SSF

Colpocleisis

Question 8

Mmemonic to explain procedure

Answer 8

P - procedure
R - Reason
E - Expect
P - Probability of cure
A - Alternatives
R - Risks
E

Question 9

Vaginal hysterectomy - PREPARE

Answer 9

P - vaginal hyst
R - Mid compartment prolapse, HMB, Hyperplasia
Fewer complications, shorter healing time, less pain, less scarring, a lower chance of infection, less risk of hernias, and faster return to activities. Also, a prolapsed uterus is easier to access via the vagina
E - 1 night in hospital, IDC, 2-6 weeks off work, 6 weeks no heavy lifting, browny discharge up to 6 weeks, no intercourse 6 weeks
P - 85% of woman will not require further intervention for their prolapse
A - TLH, TAH, SSF, sacrocolpoplexy
R: GA risks, VTE, bleeding (0-10% RBC) and haematoma (10%), infection, UTI (6-20%), injury to adjacent organs (2%, incl fistula), urinary retention (10-15%), urinary incontinence (if was occult prior to surgery, 40-45%)
E???

Question 10

Vaginal hysterectomy - steps

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
Prep and drape
BM
IDC
Speculum, 2 littlewoods to anterior and posterior lip of cervix
Hydrodissect with local anaesthetic with adrenaline and saline
Circumferential incision at junction of cervix to vaginal mucosa
Blunt and sharp dissection to reflect bladder and elevate away from surgical field with retractor and then enter uterovesical peritoneum
Blunt and sharp dissection into POD and metzenbaum scissors used to enter peritoneum
Ligation of 3 main pedicles on each side: uterosacral, uterine artery, ovarian pedicles (IP including fallopian tube, ovarian and round ligaments)
Uterosacral ligament pedicles are tagged with long sutures
Check ovaries to ensure normal
Check for haemostasis at all pedicles.
Oppose uterosacral ligaemtns using suture lengths and secure to posterior vaginal vault with MAYO needle to allow for vaginal support. (McCalls caldoplasty)
Close vaginal vault with interrupted mattress sutures or continuous locked suture.
Vaginal pack with ovestin for added haemostasis

Post procedure
- Remove IDC and pack day 1
Early mobilization
Thromboprophylaxis
Pain management
E+D as tolerated
Debrief
Post op instructions: driving, constipation, heavy lifting
Clinic FU 4-6 weeks, histo

Question 11

Abdominal sacrohysteropexy / sacrocolpopexy - PREPARE

Answer 11

P - open or laparoscopic for conservation of uterus. Sutures or mesh can be attached inferiorly to the junction of the cervix and uterus (and uterosacral ligaments) and superiorly to the anterior longitudinal sacral ligament over the first or second sacral vertebra
- Synthetic mesh - woven polypropylene
- Mesh is covered by peritoneum at end.

R - Mid compartment prolapse

E - 1-2 nights in hospital, IDC, 4-6 weeks off work, 6 weeks no heavy lifting

P - 80-90% of women are cured of their prolapse symptoms (vault prolapse - 90-98% success rate)

A - Vag hyst, SSF

R - Pain (generally or dyspareunia - 2-5%)
- Mesh exposure 2-4%
- Damage to bladder, bowel, ureter (1-2%)
- Changes in bowels - constiaption etc. 2-3%
- Changes in urination up to 10% e.g. slow emptying, retention. Usually resolves after a few weeks
- GA risks
- VTE risks
- Bleeding
- Infection

E???

Question 12

Steps of sacrocolpopexy / hysteropexy

Answer 12

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
IDC
Place vaginal probe if no uterus
Pfannenstiel incision or laparoscopic entry
Identify ureters
Incise posterior peritoneum (retroperitoneum) over the sacral promontory and dissect inferiorly clearing the periosteum of connective tissue
Incise over the vaginal apex to enter vesicouterine space and reflect bladder caudally if no uterus
Place 3 rows of sutures down the posterior vaginal wall and 2 rows of sutures down anterior vaginal wall to correct anterior and posterior compartment prolapse
OR if uterus, attached mesh to anterior and posterior uterus
Secure mesh to anterior longitudinal ligament under minimal tension at level of S1 avoiding vessels
Confirm haemostasis
Close peritoneum overlying sacral promontory
Close abdomen

Post procedure
- Remove IDC day 1
Early mobilization
Thromboprophylaxis
Pain management
E+D as tolerated
Debrief
Post op instructions: driving, constipation, heavy lifting
Clinic FU 4-6 weeks

Question 13

Sacrospinous fixation - PREPARE

Answer 13

P - SSF - cervix attached to sacrospinous ligament. Through a cut in the vagina, stitches are placed into the sacrospinous ligament int he pelvis and then to cervix or vaginal vault (permanent or absorbable sutures). Eventually they are replaced by scar tissue.
R - For mid compartment prolapse
E - IDC, pack, 2-4 weeks off work, 6 weeks no heavy lifting, 6 weeks no intercourse
P - 80-85% chance of cure
A - Sacrohysteropexy / colpopexy, colpocleisis, Vag hyst
R - GA, VTE, Bleeding, Infection, Bladder infection (6%), buttock pain (10-18%, majority will get better on its own. Pudendal neurovascualr damage - differing courses of pudendal nerve - place sutures 2cm medial to ischial spines)), constipation, dyspareunia, injury to adjacent structures, SUI (33% - occult prior), bladder emptying difficulty 10%, cystocele formation (20-30% - as exagerated horizontal axis of vagina so anterior compartment of vagina more susceptible to intrabdominal pressure)

Question 14

Steps of SSF

Answer 14

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
IDC

Open posterior vaginal wall after hydrodissection with LA with adrenaline
Retract the rectum towards the patient’s left side, away from operative field
Use blunt dissection to enter the right pararectal space to access the ischial spine
Place a retractor at 12 oclock to hold the cardinal ligament containing the ureter out of the operative field
Identify and expose the sacrospinous ligament removing any connective tissue
Place a 2-0 PDS suture using Capi ligature carrier, aiming for mid portion of the sacrospinous ligament 2-3cm medially from the ischial spine and pull through
Repeat with second suture if unilateral procedure
With a free needle (MAYO), secure the suture to the undersurface of the vaginal vault or cervix and tension to reduce prolapse. Tie suture ends
Close the posterior vaginal wall with continuous locked 2-0 Vicryl
Perform rectal exam
Place vaginal pack for haemostasis

Post procedure
- Remove IDC and pack day 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

Question 15

Colpocleisis - PREPARE

Answer 15

P - closure of the vagina - removal of vaginal mucosa and inversion of the vagina (sewing the back and front wall together) using purse string sutures. Highly effective but rate of reoperation unknown. Often combined with perineorraphy.

R - mid compartment prolapse

E - 1 - 2 nights hospital, IDC, +/- vaginal pack, 6 weeks off work, intercourse, heavy lifting

P - 90-95%

A - SSf, sacrocolpopexy / hysteropexy, vag hyst

R -
GA risks, VTE, bleeding, wound infection, bladder infection (6%), pain (particularly if haematoma in a trapped space), rectal pressure - this decreases over time, bladder and bowel injury, 1/10 women feel dissatisfied with the procedure
1/5 regret procedure as sexual intercourse is not possible after this operation.

Question 16

Steps of a colpocleisis

Answer 16

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

Apex of prolapse grasped with Allis clamp and two rectangular sections of vaginal mucosa, one anteriorly and one posteriorly are outlined for dissection
Hydrodissection
Denude vaginal epithelium, sharp dissection used to spearate vaginal epithelium from fibromuscular CT
Delayed absorbable suture such as Vicryl used to imbricate a tunnel on either side, followed by imbrication of the cervix
Box sutures are used
Once prolapse is reduced, the vaginal epithelium is approximated with an interrupted or running fashion with a delayed absorbable suture
Cystoscopy the performed
Perineorrhaphy performed to reduce lenght of genital hiatus
Rectal exam

Post procedure
- Remove IDC and pack day 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

Question 17

Anterior colporrhaphy - PREPARE

Answer 17

P - Anterior repair: midline incision in anterior vaginal wall mucosa, push back bladder through dissection and then plicate endopelvic fasica to provide support and elevate bladder and anterior vagina.

R - anterior compartment prolapse

E - 1 night in hospital, IDC, pack in

P - 70 - 90%

A - SSF, pessary, paravaginal repair (corrects lateral defects by reattaching lateral vaginal sulcus to ATFP / white line), abdominoperineal or four corner repair - sutures to paraurethra and 2 more proximally in vaginal wall –> connected to sheath, mesh repairs - not recommended - 8-15% exposure

R - GA, VTE, bleeding (1% RBC), post op infection, bladder infection (6%), dyspareunia, damage to bladder or ureters, incontinence (occult), constipation

Question 18

Anterior repair - steps of operation

Answer 18

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

Simms
Grasp apex of repair with allis and hydrodissect the anterior vaginal wall with diluted local anaesthetic with adrenaline
Make vertical incision from the apex to within 1cm of the external urethral meatus
Using sharp and blunt dissection reflect vaginal mucosa off the underlying fascia leaving the fascia attached to the bladder
Extend laterally in an avascular plane toward each pubic rami
Plicate fascia using interupted mattress sutures 2/0 PDS from the apex to the urethral meatus
Consider conservative trimming of redundant anterior vaginal mucosa
Close the anteiror vaginal wall with 2/0 vicryl continuous locked suture
Pack
IDC
Cystoscopy

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

Question 19

Posterior colporrhaphy + perineorraphy - PREPARE

Answer 19

P - posterior repair - a procedure to repair or reinforce the fascial support layer between rectum and vagina

R - posterior compartment prolapse

E - 1 night stay in hospital, IDC, pack

P - 80-90%

A - Pessary, mesh, site sepcific fascial defect repair , transanal repair performed by colorectal surgeons

R - GA, VTE, bleeding (1% risk RBC), post op infection, bladder infection (6%), constipation, dysapreunia, injury to rectum

E - WrittEn info

Question 20

Steps of posterior repair and perinorraphy

Answer 20

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

Grasp apex of vaginal repair and hydrodissect the posterior vaginal wall with dilute local anaesthetic with adrenaline
Grasp perineum ~2cm laterally either side of the midline
Infiltrate with local anaesthetic and make transverse incision
With countertraction use metzenbaum scissors to dissect proximally toward apex in a vertical fashion incising the vaginal skin as you go
Use blunt and sharp dissection to reflect the underlying fascia off the vaginal mucosa laterally to the level of the pararectal space
Site specific plication of perirectal fascia with 2/0 PDS
Consider conservative trimming if redundant posterior vaginal mucosa
Close vaginal mucosa continuous locked suture with 2/0 vicryl
Assess need for perineorraphy
Diamond incision at the perineum
Re approximate the perineal bulk with interupted sutures and then close the skin with subcuticular sutures
Perform PR
Vaginal pack for haemostasis

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

Question 21

Examination for urinary incontinence

Answer 21

BMI
Abdo and pelvic exam - masses, POP, cough test for SUI
Vaginal exam: atrophy, pelvic floor strength (0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, with lift, 5 = strong, also note duration of contraction
Neuro exam - S2-4 - deep tendon reflexes at knee and ankle
Cognitive assessment
Cough test (full bladder) - reduce POP to assess for occult SUI also, performed in supine and upright positions

Question 22

Ix for UI

Answer 22

Urinalysis
PVR
Pad test - quantify urine loss by weighing
Urethral mobility
USS
Cystoscopy if suspected urethrovaginal / vesicovaginal fistula, pain or recurrent UTI. Mandatory in women with haematuria persistent -> bladder biopsy
EMG: can be used to assess pelvic floor denervation in women with UI or POP
Urodynamics

Question 23

Describe urodynamics

Answer 23

Functional assessment of bladder and urethral function
Demonstrate an abnormality of storage or voiding
Consider if conservative management unsuccessful, mixed symptoms, surgical treatment anticipated, having surgery for a large prolapse, history of voiding dysfunction

Uroflowmetry: measure of flow rate over time (max and average flow rate, flow time, total volume voided)
- <15mL/sec abnormal
>40mL/s may indicate decreased outlet resistance (SUI)
Normal flow pattern bell shaped curve
Residual measured at end

Cystometry
- Pressure volume relationship of the bladder during filling and voiding
concurrent measurement of intravesical and abdominal pressures using catheters inserted into bladder and rectum or vagina.
- detrusor pressure = Pves - P abd
- notify of first desire to urinate, normal desire and urgency
Filling stops at 500mL unless patient reaches max bladder capacity earlier
Provocative measures - coughing, valsalva etc - used to promote leakage (urodynamic SUI if occurs in absence of detrusor activation)

Question 24

Non surgical interventions for UI

Answer 24

Conservative
- Reduce fluids
- Reduce caffeine / alcohol
- Diet advice to avoid constipation
- Weight loss
- Smoking cessation
- Review drugs

Behavioural therapy (aim to improve central control of micturition)
- Bladder retraining for overactive bladder (urge on filling without overactive bladder) - voluntary and repetitive efforts to defer urination and aim to increase intervals e.g. every hour for first week, then increase by 15-30mins each week until reach 3-4 hours. Requires patient compliance and motivation.
- Biofeedback - vaginal or rectal pressure sensors worn - patient can visualize or hear or feel increase in pressures and then can conciously inhibit them
- Hypnotherapy - OAB thought to be exacerbated by underlying pyschological factors
- Acupuncture

Physical therapies
- PFMT - 8 x on three occasions 55% reported cure or improvement
- Vaginal cones - retain in vagina when walking (no better than PFMT alone)
- Functional electrical stimulation: TENS –> inhibits detrusor muscle in DO, in SUI it directly stimulates Pelvic floor muscles

Pharmacological
- Antimuscuranic / acetylcholine meds
- SE: dry mouth, blurred vision, tachycardia, drowsiness, constipation, CNS issues
- Oxybutynin 5mg TDS -> dry mouth +++
- Solifenacin - better tolerated, 5mg OD. Efficacy after 1 week and stable after 12 weeks
- Mirabegron
- Desmopression (DDAVP) - synthetic analogue of vasopressin which inhibits diuresis but avoids vasopressive effects, used at night in patients with nocturnal polyuria, reduces nocturia by 50%. be aware of hyponatraemia
- Oestrogens - some RCT evidence for OAB, no evidence in SUI
- TCA - sE ++

Question 25

Surgical interventions for UUI

Answer 25

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.

Question 26

Sacral neuromodulation - PREPARE

Answer 26

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.

Question 27

BOTOX for OAB - PREPARE

Answer 27

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

Question 28

SUI - medications

Answer 28

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

Question 29

Surgical options for SUI

Answer 29

TVT
Burch colposuspension
Transobturator tape
intramural bulking agents
Autologous fascial slings

Question 29

MUS - PREPARE

Answer 29

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

Question 30

TVT procedure

Answer 30

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

Question 31

TOT approach vs TVT

Answer 31

Similar sucess rates
TOT higher failure rate
TOT lower visceral injury

Question 32

Burch colposuspension - PREPARE

Answer 32

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

Question 33

Burch colposuspension steps

Answer 33

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

Question 34

Autologous fascial sling - PREPARE

Answer 34

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

Question 35

Steps of an autologous fascial sling

Answer 35

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

Question 36

Bulkamid - PREPARE

Answer 36

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