Case Presentation Ahmed S. El-Azab, MD Associate Professor of Urology - Section of Female Urology & NeuroUrology - Assiut University

Case Presentation
            Ahmed S. El-Azab, MD
         Associate Professor of Urology
   Section of Female Urology & NeuroUrology
Asyut University Urology and Nephrology Hospital

Case # 1
   Ms. M. I., a 48 yr old ♀, teacher, menstruating. no
    history of diabetes or other medical condition
   CC: Urine leakage on activities as sneezing, coughing,
    episodes of urgency and UI, bothered
   P/E:
       Assess urethral support and mobility
       Stress maneuver (cough Vs. Valsalva)
       Assess pelvic organ prolapse.
            SUI obvious, stage I AVWP, ureth hypermobility
   What is Next?!

Preop. Assessment
   Voiding diary
   U/A
   VCUG
   Pad test
   Q-tip test
   Urodynamics
    ―   Indications of Urodynamics in SUI

Q-tip test

Pad Test
    Length of the test:
    Office Vs Home:
    Pyridium:
    Stress Vs. Rest:

Interpretation

Cost Effectiveness of Urodynamics
1.    Mixed incontinence, Significant urge component
2.    Before surgery
3.    Previous failed incontinence surgery
4.    Known or suspected neurologic disease
5.    History of urinary retention
6.    High PVR
7.    Elderly patient (ie, >65 y)
8.    Pelvic organ prolapse
9.    Diabetes (bladder neuropathy)
10.   Nocturnal enuresis
11.   Nulliparous woman with stress incontinence

Urodynamics

What operation?
   Mid-urethral sling; TVT vs TOT
     Same outcome!!
     Prolene mesh vs. autologous midurethral sling

     TOT easier to put but more difficult to remove

     Pain after TOT:
        Obturator n. damage  rare as it is far from trocars
         Irritation to bone (more common)

TVT Needles

Bladder

Pubic
Symphysis    Prolene Mesh
             Sling

            Picture courtesy of M. Walters

Surgery
   TOT
   On 2nd postop day
   What if she could not void? For how long you
    keep on CIC before you institute urethrolysis?
    — Immediate, 2 weeks, 4 weeks, 3 months

   On 2nd postop day catheter was removed and
    trial of voiding …. She voided with only 50 mL
    PVR
   She was discharged home

Follow up
   1 month later:
    —  she reported No SUI, but complains of urgency and
      few episodes of urge incontinence
    — What is next?

Follow up
   1 month later:
    —  she reported No SUI, but complains of urgency and
      few episodes of urge incontinence
    — What is next?

    — Timed voiding

    — Behavioral modifications

    — Anticholinergics

Follow up
   6 month later:
    — she reported No SUI, but still bothered by the
     storage symptoms of urgency and urge incontinence.
     She reported that treatment did not work that much
     to improve her symptoms
    — what is next?

Follow up
   1 month later:
    — she reported No SUI, but complains of urgency and
     few episodes of urge incontinence, still bothered
    — Differential diagnosis:

Follow up
— What   is next?
  — History
  — P/E

  — PVR  85 mL

  — U/A  free

  — Voiding diary

  — Urodynamics

  — Cysto?

Qmax: 10 mL/sec
Pdet@Qmax 64cmH2O

Question to the panel
   How would you diagnose bladder outlet
    obstruction in women?
    — could be difficult, no definite criteria!!
    — Women may not be able to void at all for a
     urodynamic study, and thus we do not have access
     to pressure flow data  Importance of the initial
     noninvasive uroflow

Asyut Experience

—  Most accepted nomograms use PdetQmax ≥20–25
  cmH2O
— Abnormal Qmax ≤11 - 15 ml/s
— free flow is more representative!!
— At our institute:
    — PdetQmax   >20 cm of water when the Qmax is ≤12 ml/s
      or
    — PdetQmax >30 cm of water when the Qmax is 12-15
      ml/s.

Urethrolysis
 This woman was scheduled for urethrolysis
 Optimal time after sling insertion:

Expert Opinions
        in
  Female Urology
Prof. Hassan Abdelatif Abolella MD,
        Professor of Urology,
         Assiut University .

Case Number (1)
OAB and small capacity:
    A 65 year – old, gravid 3, para3, Woman with history
     of overactive bladder (OAB) symptoms , present
     with refractory OAB to 3 medications that did not
     work. She stopped all medications after 3 months
     with no benefit. She describes her incontinence as
     mostly urge type .She had history of a motor car
     accident (MCA) and had local surgery for disc
     herniation for instability after MCA.

 She has had therapy with percutaneous tibial nerve
   stimulation (PTNS) before her currently referral with
   no benefit after several sessions of PTNS.
  On examination:-

     No stress incontinence with full bladder.- An
   attempt to fill her bladder with saline reveals that she
   can only tolerate a small amount of fluid of less than
   65 ml.- PVR is 35 ml, and her urine analysis is
   negative .
# How would you proceed with this patient ?

   This patient suffers from detrusor overactivity
    incontinence with small bladder capacity and
    high pressure voiding and increased EMG
    activity during voiding.

   Firstly, a second filling cycle at slow filling rate,
    instruct the patient to void without voluntarily
    contracting pelvic floor

   This patient wishes to avoid major surgery :
    Augmentation cystoplasty or urinary diversion.

# The first option is: Intradetrusor injection of
  100U Onabotulinum toxin A.

# The second option is Sacral neuromodulation.

ICI 2009 - 4th International Consultation on Incontinence
                  Recommendations of the International Scientific Committee:
Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence

Case Number (2)
 Urethral diverticulum
A 27 year-old, gravid 3, para 3, woman presents with
  several years’ history of vaginal pain and voiding
  symptoms.
Her lower urinary tract symptoms include difficulty,
  urgency, frequency and feeling of incomplete emptying.
 She has had culture documented infections every 2
  months for at least the last 12 months.

She also describes a history of stress urinary incontinence
occurring at least 2-3 times a day.

She had a past history of 3 vaginal deliveries .

Her physical examination revealed palpable suburethral
mass extended proximally to the level of bladder neck.

Her urinalysis is negative and post-void residual urine is
95 ml.
How would you proceed with her therapy ?

Culture specific antibiotic therapy.

# An inverted U –shaped incision.
Incise the periurethral fascia transversely to raise
proximal and distal flaps.
Dissection and excision of the diverticulum.
Harvest the autologous fascia and perforate the
endopelvic fascia lateral to the periurethral fascia.
Longitudinal closure of the urethral defect over urethral
catheter, transverse closure of periurethral fascia.
Midurethral sling fixed without tension to the rectus
sheath. Foly catheter is left indwelling for10-14 days.
# synthetic sling is contraindicated.

Case Number (3)
Stress incontinence and intrinsic sphincter deficiency

   A 59 – year- old, gravid 4, para 3, active woman
    presents for management of symptomatic and fairly
    severe urinary incontinence.
    She wears about 7 pads a day for protection and has
    tried anticholinergics with no improvement. She
    describes mainly stress incontinence and no overt urge
    symptoms although she states she leaks all the time
    when standing or walking.

She has no nocturnal leakage.
 Her past history is significant for some vaginal atrophy
and a pervious abdominal hystrectomy for benign disease
at which time she had a mini-sling performed for urinary
incontinence.
Her examination demonstrates easy stress incontinence
(urethral mobility 20-30 degrees). She has no prolapse.

How would you proceed ? Do you think she needs to
have her sling incised / cut if one is performing another
sling ? if so, what type of sling ?
What would you recommened ?

# Minority of patients with SUI would be classified as
predominantly having ISD (10-15%).

# Most patients presenting with SUI due to moderate or severe ISD
,defined for discussion purposes as an abdominal leak point pressure
( ALPP ) less than 100 cm at low bladder filling volumes with or
without further decreasing ALPP with increasing bladder volume
testing.

# Mid urethral retropubic sling procedures allow passive extrinsic
compression of the urethra to induce increased circumferential
urethral resistance without any degree of tension applied to the sling
arms at the time of fixation .

Pathophysiology of Stress Urinary Incontinence

• Urethral Hypermobility
 – Displacement of urethra during
   sudden increase in abdominal
   pressure
 – Decreases pressure transmission

Pathophysiology of Stress Urinary Incontinence

• Intrinsic Sphincter
  Deficiency (ISD)
   – Urethra is unable to
     generate enough
                                       Normal      Abnormal
        outlet resistance to           Closure      Closure

  keep the urethra closed
  at rest or with minimal
  physical activity

SUI Occurs When;
            Bladder Pressure > Urethral Pressure

    • Any factor that pushes                    Cough
      the equation towards                      control,
                                               weight loss
      a positive urethral
      pressure gradient
      has the potential to be                       Surgery

      effective
                                                   Exercises,
                                                   medication

.

Case Number (4)
        Sling perforation into urethra
A 43 year-old woman is referred for recurrent urinary
tract infection (UTIs) and dysuria after a transobturator
midurethral synthetic sling (TOT) .
 The sling was perfomed 5 months ago for pure stress
urinary incontinence (SUI). Since then she has had four
attacks of UTIs.
After treatment the dysuria subsides but never fully
resolves. Prior to the sling she had one UTI 25 years ago.

The patient’s voided urine has many epithelial cells and
you decide to pass a catheter to obtain a better urine
sample . As the catheter is first inserted you feel some
roughness and the patient shrieks in pain. She has mild
tenderness over the midurethra but no mesh exposure.
She has no prolapse. Post void residual urine by US was
40 ml.
 Cystourethroscopy is performed. The bladder appears
normal. There is synthetic mesh in her mid-to distal
urethra.
How would you proceed ?

# Low dose antimicrobial suppressive therapy to reduce her
risk of another UTI.
# Urine culture 1 week before surgery.

# An inverted U –shaped anterior vaginal wall incision to
excise the portion of sling which had eroded into the urethra
as well as the lateral portions of the sling up to the level of
endopelvic fascia. Closure of urethral mucosal defect
,reapproximation of periurethral fascia over the urethra.
Martius labial fat pad graft over the repair. A Foley catheter
for 7-10 days. Pull –out cystourethrogram before
catheter removal.

# Autologous rectus fascia pubovaginal sling at the

CASE 5

63 yr old female teacher
   Extreme urgency and frequency for 3 years,
    never incontinent

   Come with diagnosis of “ interstitial cystitis”
   C/O severe knife like pain with urination
   Urine +ve RBC,
   PSH:TOT 5 yrs ago for SUI
   PMH: DH, HTN
   Exam: negative pelvic exam

What would be your next step??

Next step
   Psycological Evaluation
   Vaginal Ultrasound
   Urodynamics
   Cytology
   Cystoscopy
   Send to distant center for evaluaton

Answer
   Urine cytology is frequently negative, but a negative result on
    urine cytology is not sufficient to rule out malignant tumor.

   Cystoscopy is generally indicated in patients with complicated
    OAB who have undergone prior pelvic or anti-incontinence
    surgery or are suspected of having underlying anatomic
    pathology by the nature of their initial assessment (ie, hematuria,
    recurrent infection).

   Cystoscopy is a must, moreover, complication resulting from
    TOT such as urethral fistula or erosion should be ruled out

Cystoscopy: tape appear to be in the bladder on
  the left side
 I thought this was impossible: “it is a TOT”
                            Resident comment

   How frequent ??
   Possible to miss by scope !
   How to remove it ??

Case Number (6)
Post – cystectomy prolapse

    A 55-year-old woman presents with prolapse having
     undergone a radical cystectomy and orthotopic w-
     neobladder for transitional cell carcinoma (TCC) of the
     urinary bladder 1 year ago.

    Her pathology revealed a muscle invasive TCC and her
     lymph nodes were negative. Of note is that her vagina
     was partially resected (anterior wall) along with her
     uterus ,tubes and ovaries (anterior exenteration).

   Her prolapse has developed over the last 6 months
    and is affecting her quality of life .She has difficulty in
    walking, friction, spotting and excoriation.

    On examination: -
       An obvious stage IV prolapse and her total vaginal
    length is 6-7 cm on maximal stretch / push.
    She would, ideally, like to be sexually active.

# How would you proceed with counseling her about
options?

This is very difficult and challenging case.
Surgical options include abdominal and transvaginal
approaches.
# Colpocleisis :is not an option for her as she is keen
to remain sexually active.
# Sacrocolpopexy (abdominal or lap.):surgeon
needs to be aware of the position of the neobladder and
ureters.
# Transvaginal sacrospinous ligament mesh
fixation and sutures secured it distally to the under surface
of pubic symphysis and close the gap between lateral
mesh edge and pelvic sidewall with interrupted sutures.