sign in sign up
<<
Home , Cystocele

Complications of Incontinence and Prolapse : Evaluation, Intervention, and Resolution—A Review from Both Specialties W42, 16 October 2012 14:00 - 18:00

Start End Topic Speakers 14:00 14:10 Introduction  Howard Goldman 14:10 14:35 Complications of incontinence surgery (except  Sandip Vasavada retention) 14:35 15:10 Retention/Voiding dysfunction after incontinence  Roger Dmochowski surgery 15:10 15:30 Discussion All 15:30 16:00 Break None 16:00 16:35 Complications of prolapse surgery (except  Howard Goldman ) 16:35 17:00 Dyspareunia after surgery  Tristi Muir 17:00 17:40 Discussion All 17:40 18:00 Questions All

Aims of course/workshop This course will summarize both common and uncommon complications associated with standard and new technologies used for pelvic floor reconstruction and therapy in women. The intent of this course is to present both the approach to evaluation and management of these complications from both the urologic and urogynecologic perspective of the combined faculty. The emphasis is on newer technologies and complications, both acute and chronic, which are associated with these various . The goal of this course will be to summarize, not only identification, but also evaluation and appropriate intervention, as well as patient counselling for these various complications.

Educational Objectives This course will provide a detailed paradigm for avoiding, evaluating and managing complications of incontinence and prolapse surgery. Evidence continues to accrue in this area but it runs the spectrum from Level 1 to 5 with much being expert opinion. Unfortunately, very little cross comparison exists to support these differing interventions. The intent of this course will be to summarize and use this evidence along with the expert opinion of the panel and their peers to develop a paradigm for approach of these complications. The presentations will provide detailed instruction and in particular case discussions by recognized experts in this field.

5/23/2012

Complications of Incontinence and Prolapse Surgery: Evaluation, Complications of Stress Intervention, and Resolution—A Incontinence Surgery (Slings) : Review from Both Specialties (Excluding Voiding Issues)

Sandip P Vasavada MD Sandip Vasavada, MD Roger R Dmochowski MD Cleveland Clinic Glickman Urological and Kidney Howard B Goldman MD Institute Tristi W Muir MD Cleveland, Ohio

Complications of Vaginal Sling Surgery Bleeding During Sling Surgery

• Bleeding • Urethral injury • Retropubic passage: • Infection • Neurologic injury/pain – entry into retropubic space • Sling placement/close observation • Bladder • Mesh related • Foley catheter into bladder, 60cc in balloon and injury/Perforation – Extrusions into compression – Mesh erosions into • Bladder outlet – Trochar passage urethra obstruction • Point cautery – Mesh erosions into bladder • Usually due to close passage near urethra/periurethral neurovascular compartments – Retropubic TVT passage (recognition of injury is key) • Exploration (retropubically/open): not transvaginally

Bleeding in Slings

• May occur 0.5 to 8% of time • No difference between Burch BNS and fascial slings based on SisteR trial (2009) • TOT lower likelihood of bleeding and transfusion rates overall less than 1%

1 5/23/2012

Obturator Anatomy Bleeding into Obturator Space Vasculature • Very little data Distances – Most bleeding will stop with some pressure and Medial branch vessel 3.1 cm (2.3-4.8 cm) placement of sling/compression Lateral branch vessel 4.3 cm (3.0-5.3 cm) – Foley balloon and inflate with 60 cc sterile water Device to most medial vessel 1.1 cm Device to canal 2.3 cm • What is the utility (if any) of a vaginal pack ? • case reports • Compartment syndrome potential • Use of angiography and embolization?

Courtesy of J Whiteside, MD

Bleeding during Retropubic Space Entry into Retropubic space (fascial entry slings etc..) • Entry into retropubic space – Preservation of endopelvic Levator Periurethral fascia • Enter just lateral to periurethral fascia • Medial to levator fascia and musculature • Oblique angle 30 degrees from midline towards ipsilateral shoulder

Infections Perioperative Urinary Tract infections

• Sling related infections (with new type 1 • Post‐sling UTI incidence varies from 8‐33% (Anger, meshes are extremely uncommon) Laurikainen) – Studies not designed to look at this problem – Obtape – Loss to follow‐up – ProteGen – Lack of standardized perioperative management • Urinary tract infections can occur within the – Perioperative antibiotic protocols often not standardized – Diagnostic methods not clear first month after sling surgery • Skin and vaginal infections are rare (Laurikainen) – Discharge • Overall infection after sling is 5.5 % (Paraiso) – Slowing of urine stream • Used more commonly as a metric in Outcomes – Catheters etc..

2 5/23/2012

Ob Tape Complications Infections/ Abscess 66 y/o female s/p TOT sling, fever, pain in thigh, fluctuance, no palp mass

Courtesy of Howard B. Goldman, MD Courtesy of Howard B. Goldman, MD

Bladder Injury/Perforation • Not uncommon • Most series of retropubic slings show rates of 0‐ 24% • TOT slings too • 6x less TOT • Recognized? • Cystoscopy – SUI guidelines

TVT Complications Bladder perforation • Proper recognition of entry – Fluid emanating from space (urine) – Irrigation of foley (+/‐ Indigo Carmine) – Cystoscopy • Suture passage (no further therapy) • Multilayer closure +/‐ Martius flap • No overlapping suture lines • Good urinary drainage x 5 ‐ 7 days – Cystogram to confirm healed bladder wall

3 5/23/2012

LIGHT TEST FOR CYSTOCELE Urethral Injury

• Overall low incidence (< 1%) • Again, essential to recognize injury – Careful cystourethroscopy – Reposition needle/trochars – Large injury: probably best to abort surgery (mesh) • Primary repair • Martius flap ?? • TOT incidence is extremely low but higher with outside in than inside out (BJU int 2010) Vasavada, Comiter, Raz, Urol 1999

Bowel Injury Bowel Injury

Pubic Symphysis • Recognition is again key TVT Needle • Fatal reports (several) – MAUDE database – Some from expert TVT implanters

Bowel – Can occur in antegrade slings too (Kobashi et al, 2005) • Prior abdomino‐pelvic surgery – Should this contraindicate a tvt sling ?

Picture Courtesy M.Walters

Neurologic Injury/Pain Obturator Anatomy • Trochar passage retropubically (ilioinguinal nerve branches) esp if too lateral Neuroanatomy

• TOT sling passage can injure groin nerves (higher Distances incidence in less obese patients) Post. Ob n. 4.9 cm (3.4-6.5 cm) – Runners Ant. Ob n. 4.8 cm (3.0-6.5 cm) – Athletic patients Device to Post. Ob n. 2.5 cm (1.2-3.5 cm) – Considerations for consent Device to Ant. Ob n. 2.6 cm (1.5-4.5 cm) • TOT (outside in vs inside out): at least transiently, inside out seems to have more pain/neurologic potential abn • Positioning…. Especially if longer case (prolapse etc..)

4 5/23/2012

Nerve & Vascular Injury Management of Nerve Injury

S. Pubic Ramus Accessory • Conservative (NSAIDS), rest, time Obturator Vein • Neural pain medications (neurontin etc)

Obturator • Pain injections/steroid injections Nerve • Physical therapy

Pubocervical • Removal of sling material Fascia – May not help pain

External Iliac – May elicit more trauma Vein TVT Needle

Picture Courtesy of M. Walters

Mesh Related Complications of Mesh Presentation Vaginal Sling Surgery • Extrusion (vaginal exposure) • Extrusion – • Perforation (into urinary tract) – Pain – Urethra – Dyspareunia – Bladder • Perforation • Optimal management – Pain – Urinary tract infections – Overactive bladder and irritative LUTS – Obstructive voiding symptoms – hematuria

Mesh Exposure from Slings Mesh Extrusion • Management options • Data shows incidence of less than 2% (Abdel‐ – Vaginal estrogens (limited confirmational data) Fattah et al, BJU int, 2006) – Flap coverage (small series of good results) • Most were in ObTape patients • Consent for possible need for repeat management • Etiology – Mesh excision and closure of vaginal walls • Risk of recurrent SUI – Thin flap dissection – Vaginal atrophy – Breakdown of incision lines

5 5/23/2012

Mesh Extrusion “Button‐Hole” Managing Mesh Complications • Reported series are mostly in TOT sling patients • Resolution of mesh exposure may be done • High lateral sulcus with antibiotics and estrogen cream • May elicit pain • Treat in office when mesh exposure is: – Easy to reach and near the introitus – Small and requires minimal excision • Treat in OR if mesh exposure is: – Large and requires reapproximation of mucosa

Vaginal Erosions of Mesh are Increasing in Incidence as the Use of Mesh Diagnosis of Mesh Perforation Increases • History: Erosions can be found after: – Pain – Urinary tract infections • Slings – Overactive bladder and irritative LUTS • Abdominal sacral colpopexy (open or – Obstructive voiding symptoms laparoscopic) – hematuria • Cystocele and repairs • Physical exam (tenderness suburethrally ?) • Tunneller procedures for vaginal apex • Cystoscopy (flexible) bias prolapse • Urodynamics ? Is patient obstructed ?

Urethral Perforation/Erosion Erosion into Urethra

• Presenting symptoms • Should be noted on may dictate best preop cystoscopy treatment option • Can be managed with – Elderly patient endoscopic rx (not scissors, TUR or Bugbee – Minimal symptoms but rather Holmium – Hematuria laser) – No irritative or • Follow up cysto to obstructive symptoms assure no remaining edges

6 5/23/2012

Perforations/Erosions into Bladder Perforations/Erosions into Bladder

• Optimal management again depends on patient symptoms – Endoscopic (holmium laser) – Transvesical (definitive) • Single port (Cleveland Clinic experience) • Open (allows excision of all portions of mesh) – Transvaginal (if posterior)…. Fistula potential

Bladder Perforations/Erosions Path

Conclusions Post Operative Voiding Dysfunction • Mesh use for slings is likely here to stay and Obstruction: Diagnosis and • Surgical principles in exposure (flaps) and closure are important considerations Treatment • Complications can and will occur • Recognition is key Roger Dmochowski • If postoperative recognition, complete removal (exposed and then some margin.. Will be Dept of necessary in most patients) Vanderbilt University

7 5/23/2012

Iatrogenic – repetitive urethral Etiologies instrumentation Intrinsic stricture disease • Iatrogenic –post operative for incontinence • Urethral mucosal involvement procedure (most common) • Causes • Iatrogenic – repetitive urethral – Repetitive urethral dilatation instrumentation – Prior diverticulectomy – Catheter related phenomenon – Intrinsic stricture disease • Treatments • Smooth sphincter dysfunction – Dilation – Bladder neck dysfunction – Incision • Functional – Reconstruction – Dysfunctional voiding

Iatrogenic Obstruction Voiding Dysfunction After Incontinence Surgery • True incidence after incontinence surgery not Dunn et al, Int Urogynecol J 2004; 15:25‐31 known • Medline search 1966‐2001 – Literature estimates 2.5 ‐ 24% • Retrospective collections, case reports or case cohort series – Obstruction requiring intervention • Rates of voiding dysfunction: • Contemporary sling series 1‐3% – Burch ‐ 4‐22% • TVT 1.7 ‐4.5% – MMK ‐ 5‐20% – PVS ‐ 4‐10% – Needle Susp. ‐ 5‐7% – TVT ‐ 2‐4%

Etiology Presentation

• • Obstruction / Incomplete Emptying – Excessive tension or misplaced sutures or sling • Voiding (obstructive) symptoms – Postoperative cystocele or other prolapse – “Relative” impaired detrusor contractility • Storage (irritative) symptoms – Habitual voiding by abdominal straining ‐ frequency, urgency, urge incontinence

• Storage Symptoms (Frequency/Urgency/UUI) • Recurrent UTI – DO secondary to obstruction • May have recurrent or persistent SUI with obstruction – DO without obstruction – “Sensory urgency”

8 5/23/2012

Timing of Evaluation / Intervention Evaluation

• First 3 months ‐ watchful waiting vs. early • History* intervention – Preoperative voiding and continence status – Depends on procedure done – Onset of symptoms – Type of procedure performed • 3 ‐ 6 months ‐ consider formal evaluation and – Number and type of other procedures intervention – Decision often based on degree of bother to patient • Physical Exam* – May still experience improvement – “Over correction” – Hypermobility • After 6 months ‐ condition less likely to improve – Cystocele, , rectocele, – especially for cases of retention

* In cases of retention history and physical may be all that is needed

Evaluation Urodynamics

• Endoscopy • Not always helpful in making diagnosis of – Eroded sutures obstruction after incontinence surgery – Eroded sling – Webster & Kreder, 1990 – Urethral kink or displacement • “Urodynamics may fail to diagnose obstruction” – Bladder neck mobility ‐ kinking with straining – Foster & McGuire, 1993 • Urodynamics • Urodynamics did not predict outcome – Nitti & Raz, 1994 – Videourodynamics • Pdet and Qmax were not predictive of outcome independently or together. All “acontractile” patients successful

Intervention Treatment Options • Only absolute selection criteria for urethrolysis • Conservative should be a temporal relationship between – CIC surgery and onset of voiding symptoms – Pharmacotherapy – Biofeedback – • Failure to generate a detrusor contraction Dilation (??) during urodynamics should not exclude a • Definitive patient from definitive treatment, e.g. – Surgical urethrolysis

9 5/23/2012

Definitive Treatment Options Anatomy

• Urethra may be fixed to • Urethrolysis • Mid urethral synthetic sling the pubic bone with – Transvaginal loosening or incision dense scar tissue – Retropubic – Suprameatal • Cut suspension/sling • Goal of urethrolysis is to (infrapubic) sutures completely free & – Would expect greatest mobilize urethra success if done early • Sling incision – No documented peer‐ reviewed series

Transvaginal Urethrolysis Transvaginal Urethrolysis

• Inverted U incision • Sharp and blunt dissection freeing the • Lateral dissection above urethra from the periurethral fascia undersurface of the pubic bone • Endopelvic fascia sharply perforated and • Index finger placed retropubic space between pubic bone entered and urethra

Transvaginal Urethrolysis Optional ‐ Interposition of Martius Flap Retropubic Urethrolysis

• Mobilization of urethra by sharp dissection – Restore complete mobility to anterior vaginal wall • Paravaginal repair • Interposition of omentum between urethra and pubic bone

10 5/23/2012

Suprameatal Urethrolysis Suprameatal Urethrolysis

• Curved incision above • Sharp dissection of the urethra urethra and bladder neck off pubic bone – Pubourethral, pubovesical “” incised – Retropubic space entered – Lateral attachments left – ? injury to autonomic nerves • Martius flap interposition (optional)

Urethrolysis Results Urethrolysis –Predicting N Type Success SUI Outcomes Foster & McGuire 48 Transvaginal 65% 0 • No consistent predictors of outcome Nitti & Raz 42 Transvaginal 71% 0 – Only factor predictive of failure was increased Cross, et al 39 Transvaginal 72% 3% PVR (Nitti & Raz) – Higher success in spontaneous voiders vs. those Goldman, et al 32 Transvaginal 84% 19% on cath (Foster & McGuire) Petrou, et al 32 Suprameatal 67% 3% • 74% vs. 54% – No difference for retention vs. irritative Webster & Kreder 15 Retropubic 93% 13% symptoms (Petrou, et al) • 65% vs. 67% Petrou & Young 12 Retropubic 83% 18%

Carr & Webster 54 Mixed 78% 14%

Sling Incision Pubovaginal Sling Lysis • Case report described by Ghoneim in 1995 using a vaginal graft interposition • Inverted U or midline incision

• Isolation of sling in the midline

• Later several authors reported small series of sling • Incision of the sling incision with and without interposition of vaginal wall

11 5/23/2012

Pubovaginal Sling Lysis By Midline Incision Pubovaginal Sling Lysis Nitti, et al Urology 59:47, 2002

• Freeing of the sling from the underlying • 19 women urethra – 12 dependent on catheterization – May require sharp or blunt dissection – 4 obstructive symptoms • No perforation of the – 3 predominately freq/urge and urge incontinence endopelvic fascia – 15 autologous fascia, 3 allograft fascia, 1 synthetic • No freeing of the urethra from the pubic • Outpatient procedure bone • Closure of the vaginal • 12 months mean follow‐up wall

Sling Incision Results TVT and Obstruction N Type Success SUI • Klutke, et al Urology 58:697, 2001 – 600 patients Nitti, et al 19 Midline Incision 84% • Multicenter 17% – 17 (2.8%) obstructed requiring take down • Mean time 64 days (6‐228 days) Amundsen, et al 32 Various 94% retention – Simple midline incision 9% – 100% success for spontaneous voiding 67% UUI • Mean follow up 13 months (12‐16) Goldman 14 Midline Incision 93% – 1 urethral injury 21% – 1 (6%) recurrent SUI

• If within 10 days consider “loosing” sling

Obstruction From TVT Technique of Mid Urethral Sling Loosening 1‐2 weeks • Critical to identify and cut or loosen sling • Infiltrate anterior vaginal wall with 1% • Urethrolysis without identifying TVT likely to lidocaine fail • Open vaginal suture line • In cases of early intervention (up to 14 days) • The sling is identified and hooked with a right‐ may be able to loosen by pulling down angle clamp • After 10‐14 days need to incise as TVT is • Spreading of the right angle clamp or ingrown with native tissue downward traction on the tape will usually loosen it (1‐2 cm) • Chronicallly can become a tight band • If the tape is fixed, it can be cut • Reapproximate vaginal wall

12 5/23/2012

Sling Take‐Down

• Sling incision is a simply technique with low morbidity which is applicable to all types of What Happens When sling materials – Recommended as first line treatment Urethrolysis Fails?

• When sling cannot be clearly identified, formal urethrolysis is recommended

Repeat Urethrolysis Scarpero, et al, 2002 Results Emptying • 24 women all failed at least one prior • Normal emptying with relief of obstructive symptoms in urethrolysis 22/24 (92%)

– All deemed obstructed by a combination of clinical – PVR < 100 ml 334 criteria 350 • 20/22 (91%) catheter 300 dependent patients no 250 200 Pre Op Post Op • All underwent repeat urethrolysis via longer needed to 150 transvaginal or retropubic route (surgeon’s catheterize 100 44 50 discretion) 0 • 2 non‐catheter dependent Mean PVR (ml) P=0.001 – Aggressive approach taken with complete patients had PVR = 0 mobilization of urethra off the pubic bone – Mean follow up = 14 months

Results Results Emptying Urge Incontinence Stress Incontinence • 2/16 (12%) complete • 4/22 (18%) developed Post Void Residual (ml) resolution de novo SUI 700 600 • 11/16 (69%) improved, • 2 had persistent SUI 500 but required 400 anticholinergics • 5 women had collagen 300 injection with 4 (80%) 200 • 3/15 (19%) no improved improvement 100 0 Pre Op Post Op

13 5/23/2012

“Resuspension” With Urethrolysis Resuspension With Urethrolysis • Not routinely necessary after transvaginal • De novo SUI after urethrolysis without urethrolysis resuspension – Decision for resuspension can be made at the time – Foster and McGuire ‐ 0 of surgery based on operative findings – Carr and Webster ‐14% – Recurrent SUI rates 0 ‐ 19% if no resuspension – Goldman, et al ‐ 23% of successes • Consider when there is persistent SUI • 66% responded to collagen associated with obstruction • “Loose” sling preferred

Urethrolysis Approach Flap Interposition With Urethrolysis • Vaginal approaches • Recommended for all retropubic and – Usually first approach infrapubic urethrolysis – Quicker recovery • Recommended for redo transvaginal • Retropubic approach urethrolysis – After a failed vaginal approach – Vaginal surgery contraindicated or not desired • If any doubt ‐ do it – Other abdominal or retropubic surgery – Complex cases / surgeon’s preference

Conclusions Complications of Prolapse Surgery: • Clinically significant obstruction after Prevention, Evaluation and incontinence surgery is uncommon, but occurs even in the most experienced hands Management

Howard B Goldman MD • Urethrolysis or sling incision, by a variety of techniques, is successful in restoring emptying Section of Female Pelvic Medicine and Reconstructive Surgery and relieving LUTS in the majority of cases Glickman Urologic and Kidney Institute The Cleveland Clinic Lerner College of Medicine Cleveland, Ohio

14 5/23/2012

Outline Bleeding

• Perioperative • Incidence depends on definition • Postoperative • Varies by procedure – Bleeding • Overall less than 2% require blood transfusion – Infection – Potential for significant bleeding during SSF – DVT – Voiding dysfunction – Pain/Nerve Injury – Graft complications

Bleeding Mild Bleeding

• Incidence depends on definition • Not unusual • Varies by procedure • For very small bleeders • Overall less than 2% require blood transfusion – finish procedure ‐ pack – Potential for significant bleeding during SSF • Larger bleeders • Stay 2 cm medial to ischial spine and superficial under – cautious cautery the –not necessary to go around entire – coccygeous muscle oversew with absorbable suture • Pudendal vessels and nerves lay deep to the – finish procedure and pack coccygeous and near/lateral to iliac spines.

Moderate‐Significant Bleeding Bladder Injury

• As on prior slide • Always try to close with multiple layers • If deep in vagina/ may be difficult to • Straightforward in “traditional” cystocele repair access • If doing deep lateral dissection –mesh kits • Temporary packing – May be difficult to visualize • Reapproximate tissue in that area –may only get one layer • Judicious clip placement – Disposable long – Evaluate location of ureters –check for efflux shaft – ? If mesh should be placed • Hemostatic agents –Floseal • My personal preference…. • Embolization • Leave Foley catheter for 7‐10 days

15 5/23/2012

Ureteral Injury/Obstruction During Ureteral Injury Plication • Many not diagnosed at time of surgery • May catch or kink ureters • Delay in diagnosis contributes to morbidity • 0.5‐2% • At time of surgery can remove sutures and/or • Check for ureteral efflux after sutures placed stent fairly easily (without pulling too much)/tied • If necessary remove sutures and redo

Ureteral Injury/Obstruction During Ureteral Injury during Dissection Vault Suspension • Not rare during ureterosacral ligament vault • Unusual suspension 1‐11% – More common in stage 4(3?) AVW prolapse • Ureter not far from USL • Can occur with dissection deep to • Stay medial and cephelad pubocervical fascia • Check for ureteral efflux after sutures placed – – Commonly used in synthetic mesh repairs put tension on them – I check again at end of case after all tied down • Stent/Repair/Reimplant • If no efflux –cut sutures on that side and replace

Avoiding Bladder and Ureteral Injury Rectal Injury • Can occur during rectocele repair or dissection • Appropriate Exposure for vault/enterocele • Stay in the right plane – Synthetic mesh – hydrodissection • Careful dissection – Trochars –cysto with a 70 angle lens • For stage 4 (?3) AVW prolapse –consider • Know where the rectum is at all times ureteral catheters – ? Rectal pack? • Cystoscopy to check bladder integrity and • More common during repeat rectocele repair ureteral efflux • For SSF –don’t try to force retractors into pararectal space –place gently

16 5/23/2012

Rectal Injury Postoperative Complications

• Almost always can do layered primary repair • Infection • Call colorectal surgery to help – ? safer if any medicolegal issues arise – UTI –not rare • Probably no need to keep NPO (if below peritoneal reflection) – follow the colorectal surgeons advice – Wound infection • (If planned posterior mesh –would ABORT) • Unusual • I do gentle bowel prep prior to rectocele or SSF repairs –bottle of Mag Citrate afternoon prior and enema evening prior – As much to avoid straining with BM for first few days as to have relatively clean rectum

Prevention of UTI UTI

• Sterile urine pre‐op • Simple –treat • Dose of perioperative antibiotics • Recurrent –Cystoscopy to rule out intravesical • Current recs –less than 24 hours antibiotics stitch/mesh • Avoid prolonged catheter use if possible • If catheter in longer than 24 hours consider one dose of antibiotic at catheter removal

Superficial Wound Infection Deep infection

• Antibiotics –cipro and flagyl • Pelvic abscess – • Warm baths Drain • Transvaginally –US guidance • Supportive care • Percutaneously –CT guidance – Antibiotics

17 5/23/2012

Vesicovaginal Fistula VVF

• Uncommon after cystocele repair • No mesh involved – Unrecognized bladder injury at time of repair – Transvaginal repair after tissue healed – Inadequate closure/drainage after recognized • Usually more distal than typical VVF bladder injury – Easier to access • Transabdominal repair if more comfortable with that • More common with mesh repairs approach – Deeper dissection during repair – Not necessary to wait 3 months – Placement of foreign body • Mesh involved – Will discuss with intravesical mesh

Ureteral Injury Ureteral Injury

• Mean delay to dx –5.6 days • Cysto, retrograde, stent Kim JH, Intl Urogyn J, 2006 • Multiple presenting symptoms – Suture removal often necessary – Incontinence • Percutaneous nephrostomy – Flank pain – Antegrade stent – Sepsis • Reimplant – Ileus – Usually at a later date –after stent/nephrostomy – 5% “silent” ‐ dxd later as non‐fxn/hydro kidney • Typically some CT abnormality noted first – Hydroureteronephrosis down to pelvis

Selective sling at time of POP surgery Voiding Dysfunction

• De‐Novo Stress Incontinence • If could demonstrate SUI on UDS or when • Urge Incontinence placed – sling placed • Difficulty Emptying – Risk of intervention from sling 8.5% – Risk of intervention for sui with no clinical or uds hx of sui ‐ 8.3% • Covered in previous lecture – Risk of sui when hx positive for sui (but uds and packing neg for sui) – 30%

Ballert, JN, et al, J Urol, 2009

18 5/23/2012

What I Do New Urge Sxs

• If doing POP repair • Make sure not in retention – History (even in past) of SUI – recommend sling • Evaluate for obstruction – No history of SUI but when bladder filled and POP • If continues for significant period of time reduced –SUI – recommend sling make sure no foreign body in bladder – No hx of SUI and unable to elicit any SUI – counsel against concomitant sling • Treat above • Treat as typical OAB

“Nerve Pain” Biologic Graft Complications

• Can occur with deep bite of USL • Infections/Fluid collections – Usually spontaneously drain • Buttock pain in 10‐15% of SSF suspension • Extrusion/Wound healing – May be due to nerve within SSF‐coccygeous – May reepithelialize – Usually temporary – May require removal – Anti‐inflammatories/time

• Rare cases may require stitch removal

Lowenstein L, et al, Intl Urogyn J, 2007

Synthetic Graft Complications Incision of Arm

• Palpate arm • Pain • Inject local in fornix • Vaginal Extrusion • Incise over arm • Intravesical Erosion • Get around arm • Rectal Erosion • Incise arm

19 5/23/2012

Pain At Body of Mesh Rectal Erosion of Mesh

• Initial conservative management • May be assymptomatic or can cause • If persists remove significant morbidity – If not extruded –important to map out the exact • Probably under‐reported as most do not do areas of tenderness to make sure those areas are routine rectal exams removed at time of surgery • Risk factors – Previous rectocele repairs – Rectal disease –can lead to disasters • Inflammatory Bowel Disease • Diverticulitis

Mesh Extrusion Mesh Extrusion ‐ Management

• 3‐15% ‐ depending on series • Observation –if not sexually active and not • Prevention symptomatic – Pre‐op hormonal cream • Hormonal cream –I have not had much luck – Dissect and place deep to pubocervical fascia • Trim in office –very small exposures – Ensure mesh lays flat • Remove in OR – Avoid excessive vaginal wall trimming

Removal of Mesh Experience with Mesh Removal

• Decision of whether to remove just localized area of • Avg age –60 mesh vs all mesh • Prior medical tx –84% – Based on sxs, pain, etc • Latency to presentation 17 wks (0‐96) • Infiltrate with lidocaine with epinephrine • Excise skin edges • Indication for removal • Symptomatic mesh erosion 12 (63) • Undermine and remove mesh 1 cm from skin edges • Recurrent 8 (42) • Utilize sharp and blunt dissection • Chronic pain 6 (32) – Kitner/peanut • Dyspareunia 6 (32) • 3 (16) • Posterior –may benefit from finger in rectum • Multiple indications 16 (84) • Close vaginal skin Ridgeway B, Am J Obs Gyn, 2008

20 5/23/2012

Experience with Mesh Removal Intravesical Mesh Erosion

79% excised transvaginally • May be associated with VVF Follow up –16‐75 weeks Pain scores –0 (0‐8 scale) • Can approach abdominally or transvaginally 87% free of presenting symptoms • Most have reported a transabd approach

Ridgeway B, Am J Obs Gyn, 2008

Intravesical Mesh Erosion Complications of POP Surgery

• May be associated with VVF • Perioperative • Postoperative • Can approach abdominally or transvaginally – Bleeding • Most have reported a transabd approach – Infection – DVT – Voiding dysfunction • I prefer transvag approach – Pain/Nerve Injury – Good exposure – Graft complications – Minimal morbidity – Can remove almost all of mesh under bladder

Complications of POP Surgery

• Prevention is the best treatment • Identify at time of surgery –lowest morbidity Dyspareunia Following if dealt with then Prolapse Surgery • Mesh repairs have introduced a number of new potential complications Tristi W. Muir, MD • Even with significant complications –most Associate Professor patients can be treated with minimal residual Director, Pelvic Health and Continence Center University of Texas Medical Branch, Galveston morbidity • Key is identifying problem and knowing how to deal with it

21 5/23/2012

Dyspareunia Objectives Etiology • To develop an understanding of the possible • Landscape etiologies of dyspareunia • Nerves • Explore the literature on frequency of pelvic • Muscles surgery related dyspareunia • Mind • Construct strategies to avoid de novo post‐ • His problem operative dyspareunia • Evaluate dyspareunia treatment plans‐ who, what, when and where?

Landscape Vaginal Dimensions

• G‐spot disruption • Vaginal length and caliber decreases • Vaginal narrowing significantly • Erosion • No correlation with sexual function and • Vaginal lubrication decreased vaginal dimensions • Dyspareunia increases in women undergoing prolapse surgery (8% Vs. 19%) • Sexual satisfaction improved with sexual function (82% Vs. 89%)

Weber, 2000

Vaginal Atrophy Atrophy

• Affects 10‐40% of • Estrogen postmenopausal • Vaginal lubricants women • Symptoms‐ vaginal • Foreplay dryness, pruritus, • Regular sexual activity bleeding dyspareunia

22 5/23/2012

Erosion Prospective Clinical Assessment of the Transvaginal Mesh Technique for Treatment of Pelvic Organ Prolapse‐ 5 Year Results • Healing – Vascularization

– Collagen formation Complication Number affected % affected Surgical – Age (N=85) intervention N(%) – Estrogen status Mesh erosion 15 17.6% 7 (8%) – Immune status De novo 33.5% dyspareunia – Avoidance of hematoma and infection

Miller, D et al. Abstract AUGS, 2010

Late Erosion Vaginal Dimensions

• More common in sexually active women • Dilator (17.3% Vs. 2% respectively)‐ OR 10.47 • Estrogen • Kaufman 2011 • Physical therapy • Surgery

Nerve Entrapment and the Nerve Entrapment and the Uterosacral Vaginal Vault Suspension Uterosacral Vaginal Vault Suspension

• 7/182 women with USVVS with nerve entrapment • Symptoms • Treatment – Removal of ipsilateral US suture – Treatment with PT and gabapentin

Siddiqui NY et al. Obstet Gynecol 2010;116:708‐13. Flynn MK et al. AM J Obstet Gynecol. 2006;195:1869‐72.

23 5/23/2012

Nerve Entrapment and the Abdominal Sacrocolpopexy Vs Sacrospinous Ligament Fixation Sacrospinous Ligament Fixation • Randomized trail • N = 52F/U 38 months • N=95 • 3/52 with de novo dyspareunia • Impact of sexual function secondary outcome – 2 resolved with suture removal

Baumann M. et al Surg Endosc. 2009;23:1013‐7. Maher CR et al. American Journal of Obstetrics and Gynecology (2004) 190, 20e6

Trocar Systems Mesh Arms

“Trocarless” Placement

Natural Anatomy View

MVU10430 rev A

24 5/23/2012

Pelvic Pain Following Mesh Kits: Vaginal Mesh Placement Tricks

• Thick vaginal flaps • Avoid tension • Avoid “bunching” of mesh • Use vaginal estrogen prior to and after surgery • Know your anatomy, mesh and what to do Bohrer JC et al. Obstet Gynecol 2008; 112: 496‐8 if you have a complication

De novo dyspareunia estimated to be at least 3%

Vaginismus Evaluation of Pelvic Floor Muscles

• Affects 1‐7% of world’s population

Montenegro M et al. Pain Medicine 2010;11:224‐8

Pelvic Floor Muscles Botulinum toxin type A injections Treatment • Dilators • Initial injection‐ 10 • Physical therapy Units at 5 sites • 1 month later‐ 10 Units • Trigger point injection‐ at 4 sites • Botulinum toxin type A

Park, Amy; Paraiso, Marie Obstet Gynecol. 2009;114:484‐487

25 5/23/2012

It’s all in their head Hispareunia

• Complexity of female – Physical health of both people – Emotional health • Body Image • Partner’s reaction to prolapse and surgery – Intimacy of their relationship

Treatment Erectile dysfunction Erosion • Micro‐erosion • Most men >45 years of age have ED at least – Estrogen cream some of the time – Colposcope may be helpful to identify and cut • Projected to affect 322 million men worldwide mesh by 2025 • Macro‐erosion • Severity and prevalence increase with age – Estrogen cream – Excision with vaginal flap advancement – Combination

La Vignera S et al. Androl. 2011 May 19. [Epub ahead of print]

Treatment of ED How can we avoid it?

• PDE5I • Pick the right patient • vacuum erectile device (VED), • Pick the right procedure • intraurethral medication, – Are there procedures we should avoid? • intracavernosal injection (ICI), – Do we know? – • androgen supplement, What directions do we need to follow to answer our questions • α‐blocker • Perform the procedure correctly • combinations • Preoperative counseling

26 5/23/2012

Treatment Dyspareunia Happens Nerve Entrapment • Evaluation – Moderate‐ Severe – Severity • Remove the sutures as quickly as possible – Time course – Mild –Moderate (getting better???) • Reassurance – Location • Trigger point injection

Counseling Dyspareunia Happens

• Multidisciplinary Options • Treatment plan • Pre‐operative counseling • If severe‐ be aggressive • Treat the underlying pain • Evaluate etiology • Sexual counseling • Treat with • Physical therapy – Estrogen • Treat atrophy – Dilators – Injections – Surgery – Lean on associates » Physical Therapy » Sexual counseling

Complications Case Presentations • Complications will occur

• Proper planning can help minimize them • Proper evaluation can readily identify them • Proper treatment can make sure that most complications can be treated with little residual morbidity

27 Notes Record your notes from the workshop here