Stress Urinary Incontinence

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Stress Urinary Incontinence

• MONARC vs. Paravaginal wall Repair A system and
  surgeon perspective
• Dr. Richard McClain, MD, FACOG
• Chief of OB/GYN, Chickasaw Nation Health System

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The Problem

• Symptom- the complaint of involuntary leakage of
  urine during effort, exertion, coughing or
  sneezing
• Sign-The observation of leakage from the urethra
  synchronous with cough or exertion or
  spontaneously

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DEFINITION OF URINARY INCONTINENCE
The objective loss of urine that presents a
social or hygienic problem to the individual.
Incontinence is not a normal part of aging nor
is it a disease.
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IN THE U.S.

• Approximately 11 million women suffer from
  incontinence4
• Urinary incontinence occurs in1
• 50 of otherwise healthy women at some stage in
  their lives
• Roughly 20 of women between the age of 15 and 64
• About one-half of the elderly have episodes of
  incontinence

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STRESS URINARY INCONTINENCE (SUI)
Involuntary loss of urine during exertion
(lifting, jogging, sneezing, laughing)

• CAUSES
• Pregnancy and childbirth
• Pelvic injury or surgery
• Estrogen deficiency
• Weak pelvic floor muscles
• Back injury or surgery

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(SUI Continued)

• TWO MAIN CATEGORIES
• HYPERMOBILITY
• Loss of urine related to movement of the bladder
  neck and urethra triggered by abdominal straining
  (lifting, jogging)
• INTRINSIC SPHINCTER DEFICIENCY (ISD) Leakage of
  urine with minimal exertion related to an
  intrinsic weakening of the bladder outlet closure
  mechanism

Most Common in Women
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URGE INCONTINENCE
Sudden, uncontrollable urge to void, resulting in
leakage of urine

• CAUSES
• Urinary tract or vaginal infections
• Bladder tumor/stones
• Neurological causes (MS, Parkinsons, spinal cord
  injury)

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CLINICAL EVALUATION

• by a Thorough evaluation physician
• History symptoms, bowel habits, medical history
• Physical Examination neurologic examination,
  abdominal exam, pelvic examination
• Urodynamics a series of diagnostic tests used to
  measure how the bladder fills, stores and expels
  urine

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My Approach

• Subjective- affects lifestyle/activity, Sandvik
  Severity Scale and Incontinence Quality of Life
  Questionaire (included)
• Objective- leaking with cough or Valsalva in the
  clinic
• Conservative therapy- one month trial of Kegels
  exercises and Ditropan
• Urodynamics for special cases

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SURGICAL TREATMENTS

• The goal of a surgical procedure to correct SUI
  is to
• Reposition the bladder neck to minimize
  hypermobility of the urethra during stress
• Improve the coaptation of the urethra so it
  closes more effectively

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HYPERMOBILITY

• Needle suspensions (Urethropexies)
• Stamey, Raz, Gittes
• Retropubic suspensions (Urethropexies)
• Burch, MMK
• Sling procedures
• Suprapubic and Transvaginal

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ParaVaginal Wall Repair

• -Retro pubic repair that seeks to recreate
  normal anatomy
• -Modified to include a mid-urethral stitch in
  some patients
• -Requires transverse incision
• -Equivalent success to Burch Colposuspension
• -Gold Standard for SUI surgery

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SLINGS vs. OTHER SURGICAL INTERVENTIONS

• Addresses hypermobility and ISD
• More durable than bulking9
• Least invasive surgical procedure - same day
  surgery is common
• AUA Guidelines indicate slings most effective
  surgical procedure for long-term treatment of
  female SUI

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The Monarc Subfascial Hammock a Transobturator
Approach

• Helical needles centered over shaft designed to
  avoid retropubic space perforation
• Outside-to-in design optimizes safety
• Loosely knitted polypropylene mesh for fibroblast
  in-growth and integration
• Unique, patented tensioning suture prevents
  distortion during sling placement to minimize
  potential for overcorrection
• 3 needle choices for physician preference

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Reasons to Consider Monarc

• Reproduces natural suspension mechanism
• Minimizes risk for overcorrection / dysuria
• Safe passage
• Needles move immediately away from obturator
  canal
• Anatomically designed needles minimize risk for
  vascular, bowel, bladder injury
• Cystoscopy optional
• Designed to be easy to learn and to teach
• Salvage procedure after failed retropubic surgery

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Inferior Epigastric Vessels
Obturator vessels
Ext. Iliac Vessels
3-4 cm medial from the obturator canal
Monarc mesh lies below the endopelvic fascia
Courtesy of Dr. Walters, Cleveland, USA
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Monarc Mesh Position
SPARC/TVT
Monarc
Reiffenstuhl ,Platzer Knapstein
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Needle Path

• Use thumb of hand in vaginal incision to
  perforate
• Rotate the needle after obturator membrane
  perforation to exit the vaginal incision

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Why Utilize the Monarc (Outside-In)
Transobturator Approach?

• Reproduces natural suspension mechanism
• Minimizes risk for overcorrection / dysuria
• Safe passage
• Needles move immediately away from obturator
  canal
• Anatomically designed needles with centered helix
  minimize risk for vascular, bowel, bladder injury
• High efficacy with relatively little
  post-operative pain
• Backed by clinical data!

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System Issues

• Efficacy of current procedures
• Patient Benefit of new procedure
• Safety of new procedures
• Cost of the procedure/kit
• Credentialing for new procedures

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System Issues

• Efficacy of current procedure- were doing Burch
  with 50 effectiveness, had been doing TVT and
  SPARC
• Higher than expected bladder perforation rate
• Post operative hospitalization for Retro-
• pubic procedures was 76 hours (3rd day)

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MONARC- Pre op post op
pre op post
op Sandvik Scale-8/8 0/8
Incontinence quality of life- 35/92 92/92
6/8 6/8

30/92 34/92 3/8
0/8
60/92 92/92 8/8
0/8 35/92 92/92
6/8 0/8

54/92 92/92 8/8
1/8
28/92 71/92
3/8 1/8
58/92
88/92 8/8 0/8
35/92
92/92 4/8 0/8
43/92
90/92 8/8 0/8
23/92
92/92 6/8 0/8
35/92
92/92 Complications- one pt with hesitancy/slow
flow, one patient with continued self cath and
subsequent release, one repeat procedure for
recurrence due to pneumonia PVW repair Pre
op post op
pre op post op Sandvik Scale-
8/8 0/8 Incontinence quality of
life- 28/92 91/92
8/8 0/8
25/92 92/92
6/8 6/8
66/92
87/92 8/8 1/8
44/92
92/92 8/8 0/8
28/92
91/92 3/8 0/8
59/92
92/92 Complications- return to OR for bowel
complications
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System Issues

• Have health system policy that addresses cost,
  safety and workload impact issues
• Credentialed based on evidence for didactic and
  practical training with appropriate review of
  outcomes
• Did cost analysis and subsequent bulk buy of kits
  based on need

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Outcome for our Facility

• Monarc/SPARC- 70 procedures done
• Average operative time- 45 minutes
• Post-operative stay- 34 hours
• 10 done as an outpatient
• Decreased bed usage translated to fewer transfers
  
• Patient recovery time markedly improved

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Outcome for our Facility (cont)

• Reproducible between providers
• Significant improvement in patient satisfaction
• Enhanced reputation/standing in the eyes of the
  patients and community

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Pearls from Experience

• Make sure patients understand that some will have
  to be tightened, loosened or replaced
• Not all incontinence is treated with surgery
• No one can guarantee theyll never leak again
• Cystoscope everyone!!