Point Counterpoint Discussion  

   Is TOT enough to ISD Patients?

좌장 : 박원희 ( 인하의대 )      

    Yes      No 이동환 ( 가톨릭의대 )       주명수 (

울산의대 )

Introduction

• In women with SUI, a spectrum of urethral characteristics ranging from a highly mobile urethra with good intrinsic function to an immobile urethra with poor intrinsic function; urethral hypermobility and ISD

• There is no standardized terminology or definition for ISD.

• McGuire, 1982, referred to ISD as type III incontinence, which he defined as low urethral closure pressure in the proximal urethra regardless of the degree of urethral mobility.

• In failed cases with previous suspension technique, presence of ISD suspected --- Pubovaginal sling as the choice

• Integral theory by Petros and Ulmsten, 1990; TVT, 1996, by Ulmsten

• TOT, 2001, by Delorme

• Current sales of MUS devices in USA; Transobturator slings make up just over half of the total synthetic sling procedures performed.

• Key words; ISD, TVT, TOT

ISD 가 있는 SUI 환자의 수술적 치료로서 ;

1.TVT (or SPARC) 를 사용한다 .2.TOT 도 상관없이 사용한다 .3.Pubovaginal sling 을 여전히

사용한다 .

ISD 의 정의는 ?

• Maximum urethral closure pressure (MUCP) of 20 cm H2O or less by Sand et al., 1987

• Valsalva leak point pressure (VLPP) of less than 60 cm H2O By McGuire et al., 1993

• Other evaluation method ?

ISD 의 definition

• VLPP<60 cmH2O or MUCP<20 cmH2O

• Medscape Women Health(1996): Selecting the best surgical option for SUI. Traditional urodynamic evaluation of SUI focusing on MUCP has been found to be less useful than VLPP in detecting ISD.

• VLPP<60 cmH2O : ISD

• VLPP>90 cmH2O : urethral hypermobility

Int Urogynecol J pelvic Floor Dysfunct(2001) Ulmsten

• 49 명의 ISD 환자에서 TVT 시행 후 4 년간 follow up.

• 74%-cured, 12%-improved( 총 86% 에서 성공 )• 실패한 7 명 중 대부분이 70 세 이상의 고령이고

MUCP 가 <10 cmH2O 이하 • Correlation of MUCP, LPP & incontinence

severity measure(Int Urogynecol J,2001): MUCP 와 LPP 가 낮을 수록 요실금의 정도도 심하

다 . 따라서 이들 수치로 요실금의 정도를 예측할 수 있고 , ISD 를 평가하는 기준이 된다 . 그러나 이들 수치가 pad test 양 , QOL 과는 상관없다 .

기타 ISD 를 확인하는 방법

• Int. Urogynecol J Pelvic Floor Dysfunct(2002) : video-UDS 로 resting 시 및 복압증가시 bladder neck의 모양으로 ISD 를 다시 A,B,C 의 subtype 으로 구분 .

• 2008 년 Smith & Appell 등은 ISD 환자는 요도의 저항이 낮으므로 UFM 시 요속이 정상보다 더 빠를 것이라고 생각(superflow), UFM 로 ISD 를 예측할 수 있지 않을까 라고 주장

• 2006 년 Olivera 등 – translabial ultrasonography 로 urethra diameter 를 측정 , 6 mm 이상이면 ISD 라고 주장

• 가장 최근 Klarskov(J Urol. 2009), urethral pressure reflectometry(very thin, highly flexible polyurethrane-bag into urethra) 로 요도 전체의 압력을 측정하는 방법을 제시

Is it possible to diagnose ISD in women ?

Curr Opin Urol. 2009

• There’s some evidence women with ISD have a poorer outcome if they are treated by TOT compared with TVT.

• There have been some attempt at using ultrasound to identify ISD, but without any definite conclusion.

• Conclusion: ISD is an imprecise diagnosis.

Definition of ISDDefinition of ISD

• Low pressure urethra: • Indicator of ISD• Depends on age, measuring methods, circumstance

• 1976 년 McGuire• 수술 실패와 연관된 요인으로 저요도압을 보고

• AHCPR (Agency for Health Care Policy and Research)• A cause of genuine stress incontinence: ‘. . . which may be due to

congenital sphincter weakness such as myelomeningocele or epispadias or may be acquired after prostatectomy, trauma, radiation, or sacral cord lesion. In this condition, the urethral sphincter is unable to coapt and generates enough resistance to retain urine in the bladder, especially during stress maneuvers. In women, ISD is commonly associated with multiple anti-incontinence procedures. Patients with ISD often leak continuously or with minimal exertion.

McGuire EJ, Lytton B, Pepe V, Kohorn EI. Stress urinary incontinence. Obstet Gynecol 1976;47:255–264

Definition of ISD:Assessment

Definition of ISD:Assessment

Bent AE. Selection of treatment for patients with stress incontinence. Int Urogynecol J 1999;10:213-4

ISD 의 임상적 의미는 ?

• ISD 유무에 따라 수술 방법의 선택이 달라지나요 ?

• 어떤 수술을 시행하더라도 tension조정이나 다른 특별한 방법을 사용하나요 ?

Clinical significance of ISD

• Int Urogynecol J Pelvic Floor Dysfunct(2002): VLPP and/or MUCP is abnormal, incontinence is more severe and the incidence of poor prognostic factors is increased.

• Neurourol Urodyn(2003): ,,,we divided the patients into two categories: 50 patients affected by pure ISD as they had severe SUI and no urethral mobility, 42 patients suffering from SUI without ISD as they had mild SUI and marked urethral hypermobility.

• 즉 , ISD 는 AI 에 비해 요실금의 양도 많고 , 빈도도 잦다는 의미로 해석될 수 있다 .

• Definition of mild, moderate, severe incontinence on 24-hr pad test: BJOG(2004) -24 시간 pad test 에서 측정된 실금의 양을 기준으로 mild 는 1.3~20g, moderate 는 21~74 g, severe 는 75 g 이상으로 하자 .

• 이 결과에 따라 보존적 치료를 할 것이냐 , 아니면 수술을 선택할 것이냐를 결정하고 , 수술 후 cured, improved, 또는 failure 를 판단하는데 도움을 줄 것으로 기대 .

ISD affects the choice of surgical methods ??

• Surgical Treatment of SUI: Eur J Obstet Gynecol Reprod Biol (1999) : International classification as: Type 1 & Type 2(AI), and Type 3(ISD).

• Procedure of choice for Type 1 & Type 2 is BNS that create a strong hammock. Type 3 has to be treated by coaptation or compression of the deficient sphincteric unit(sling or injection). Mean cure rate after MMK is 77%, Burch is 81%, needle suspension is 79%. Laparoscopy, bone anchor & TVT represent a promising option to the traditional techniques.

Curr Opin Urol(2004)

• There remains NO clear consensus as to whether UDS enhances surgical outcome of SUI by improving case selection or altering the surgical approach based on study finding.

• It is NOT apparent either VLPP or MUCP can accurately predict which patients will achieve the best outcome of surgical treatment for SUI.

Clinical significance of ISD

Ghomiem GM et al. Int Urogynecol J 2002:13:99-105

• Grade of ISD • ISD A : medical, with collagen injection being used for the

failed cases• ISD B : modified PVS (can correct IDS and hypermobility)• ISD C : urethrolysis and take down of previous suspension

was required before using a sling, collagen injections in selected cases

Clinical significance of ISD

Pajoncini C et al. Int Urogynecol J 2002:13:30-5

• MUCP and VLPP : different mechanism?

• VLPP ≤ 60cmH2O

• more severe incontinence• Shorter urethral functional

length• Previous urogynecological

operations• Poor urethral mobility

• MUCP ≤ 30cmH2O • more severe incontinence• Shorter urethral functional

length• Previous urogynecological

operations• Menopause• Older age

Surgical options in ISD

• Pubovaginal sling• TVT : initial and failed cases• TOT : 낮은 성공률을 감안하여 환자와 상의 , tension • Injection therapy : initial and adjuvant

(hypermobility)

Lee KS et al. J Urol 2007:178:1370-4

ISD 환자의 수술적 치료에서 수술방법에 따른 성적의 차이가

있나요 ?

• 수술 방법의 차이에 대한 evidence 수준은 ?

ISD 유무에 따른 수술 후의 성적

• 2004 년 Rodriguez(J Urol): 174 명의 환자에 sling 수술

• VLPP-not detected(60 명 ), >80(27 명 ), 30-80(71 명 ), <30(16 명 ) 으로 구분

• VLPP 치와 무관하게 대부분에서 성공률이 높았다 • 2007 년 Porena 등 (Eur Urol): VLPP>,<60,

MUCP>,<30 으로 나누어 TVT, TOT 를 시행 , 각 군간에 그리고 수술방법간에 차이가 없다 .

MUS to ISD Patients

Rezapour M et al. Int Urogynecol J 2001;(Suppl 2):S12–14Doo CK et al. Eur Urol 2006:50:333-8

• TVT in ISD patients (3-4year FU)• SUI / recurrent / ISD 84.7% - 90% / 82% / 74%

• TVT 5year FU (retrospective)

TOT to ISD Patients

Hsiao SM et al. Urology 2009:73:981-6Chen HY et al. Int Urogynecol J 2007:18:443-7

Abdel-fattah et al. Int J Gynecol Obstet 2010 in pressSchierlitz et al. Obstet Gynecol 2008:112:1253-61

Miller JJ et al. Am J Obstet Gynecol 2006:195:1799-804

• Risk factors for MUS • Preop DO and MUCP ≤ 40cmH2O (TOT Monarc)

• Age ≥ 60years, previous anti-incontinence surgery (TVT-O)

• MUCP ≤ 30cmH2O, previous anti-incontinence surgery (TVT-O, ARIS)

• TOT comparison to TVT • Cure rate worse in TOT; possible explanation is ISD (RTC)• Monarc: 6 times more likely to fail than TVT in pts c MUCP ≤

40cmH2O

TOT to ISD Patients

Jeon MJ et al. . Am J Obstet Gynecol 2008:199:76.e1-76.e4

• PVS, TVT, TOT (2years, retrospective)

ISD only 환자와 ISD + hypermobility 가

있는 환자의 수술 방법을 다르게

시행하나요 ?

The role of urethral hypermobility and ISD on the outcome of TOT procedure:

prospective study - Int Urogy J Pelvic Fl Dysf, 2010

• group I, ISD with hypermobile urethra (n = 18) group II, ISD with fixed urethra (n = 16)

group III, hypermobile urethra without ISD (n = 31)

• RESULTS: The cure and improvement rates of groups I and III were similar(87.5% vs 96.4%). Group II had the lowest cure and improvement rates (66.7%).

• CONCLUSION: A lack of urethral hypermobility may be a risk factor for TOT failure.

TOT to ISD with UHM Patients

Haliloglu B et al. Int Urogynecol J 2010:21:173-8

• 2 year FU

• ISD VLPP ≤ 60cmH2O

• Hypermobile urethra Q tip >30 degree

• ISD with hypermobile urethra 87.5%• ISD with fixed urethra 66.7%• Hypermobile urethra without ISD 96.4%

• Lack of hypermobility may be a risk factor for TOT failure

소견 정리

• 이동환교수 ; ISD 환자에게 TOT 를 해도 정말

괜찮나요 ?

• 주명수교수 ; ISD 환자에게 TOT 는 성적이 좋지 않아서

정말 TVT(or SPARC) 를 시행해야 하나요 ?

소견 정리

• 이동환교수 ; ISD 환자에게 TOT 를 해도 정말 괜찮나요 ?

• 주명수교수 ; ISD 환자에게 TOT 는 성적이 좋지

않아서 정말 TVT(or SPARC) 를 시행해야만 하나요 ?

My principle

• Check VLPP and MUCP• Urethral hypermobility, fixed urethra• Previous pelvic surgery such as radical

hysterectomy• Failed cases or initial case• Age and activity• Patient expectation, compromise cure rate?• Voiding function: MFR, curve pattern, Pdet• Injection therapy as a initial or adjuvant therapy• More tension ?

증례 토의

증례 1; ISD + OAB sx 이 있는 환자의 수술 방법의 선

택은 ?

F/53C.C; Urinary incontinence, aggravated, 1 year agoP.I;Voiding Sx.:Frequency(+,q1hr), Nocturia(+,#1/N), RUS(+), Urgency(+), UI(-), Hesitancy(-), dysuria(-), abd.strain(-)Incontinence Sx. : Coughing (+),Laughing (+), Running (-) Weight bearing (-) Walking (+),Resting (-) P.Hx DM(+), HTN(+), Pul Tbc(-), hepatitis(-)PEx Cystocele(-), Rectocele(-)

<UDS> MCC: 300ml, Uninhibited contraction(-) UFR : Qmax:27.9ml/sec Voided vol:189ml RU :21ml

Leak point pressure -100cc bladder filling cough pves 38cmH2O -> mild leakage valsalva pves 53cmH2O -> mild leakage -150cc bladder filling cough pves 66cmH2O -> mild leakage valsalva pves 30cmH2O -> scanty leakage

# Pad test : 12.2gm

Sling operation(MONARC) was done

OPD f/u, 3 months later

: leakage(-), urgency(-)

증례 2; ISD 환자인데 타 병원에서 TOT 를 한 환자가

재발했다 . 그 다음 수술 방법의 선택은 ?

F/55C.C Urinary incontinence, 1 year agoP.I 내원 4 년 전 개인 산부인과 병원에서 Sling op(TOT) 시행 받은 분으로 1 년전부터 Urinary incontinence 재발했음 .

P.Hx DM(-), HTN(-), Pul Tbc(-), hepatitis(-) OP Hx: Sling op(TOT) d/t SUI (‘2006)

R.O.S Voiding Sx. : Frequency(-) Nocturia(-) Urgency(-) UI(-) RUS(-) WUS(-) Hesitancy(-) dysuria(-) abd.strain(-) Incontinence Sx. : Coughing (+), Laughing (+), Running (+) Weight bearing (-), Walking (-), Resting (-)P.Ex

Cystocele(-) Rectocele(-)

<UDS> MCC: 310ml , Uninhibited contraction(-) UFR : Qmax:20.6ml/sec Voided vol:147ml RU :36ml

Leak point pressure -110cc bladder filling cough pves 97cmH2O -> mild leakage valsalva pves 44cmH2O -> mild leakage

# pad test : 1.3gm

증례 3; VLPP 가 64 인 환자를 본원에서 TOT를 했는데 약간 좋아졌지만 여전히 샌다 .

어떻게 해야 하나요 ?

F/63C.C; Urinary incontinence, 8 year ago

P.Hx DM(-)/ HTN(+)/ Pulm Tb(-)/ hepatitis(-)

S/P ESWL#3 d/t Ureter stone, upper, Rt ('98,'03) S/P spine op d/t herniated lumbar discVoiding Sx. :Frequency(+,q1hr) Nocturia(+,#2/N) RUS(+) WUS(+) Urgency(+) UI(+) Hesitancy(-) dysuria(-)

abd.strain(-)Incontinence Sx. : Coughing (+),Laughing (+), Running (-),

Weight bearing (-) Walking (-),Resting (-)

P.Ex Cystocele(-) Rectocele(-)

<UDS> (2009.04.15)

MCC: 310ml, Uninhibited contraction(-)UFR : Qmax:13.1ml/sec Voided vol:161ml RU :13ml

Leak point pressure -100cc bladder filling cough pves 49cmH2O -> mild leakage valsalva pves 76cmH2O -> mild leakage -150cc bladder filling cough pves 89cmH2O -> mild leakage valsalva pves 64cmH2O -> mild leakage# Pad test : 6gm

Sling operation(MONARC) was done (2009.04.16)

Postop 3 mo ; still leakage

Re-admission(2009-8-20)

Voiding Sx. : Frequency(+,q1hr30min), Nocturia(+,#3/N), RUS(-) WUS(-), Urgency(+), UI(+), Hesitancy(-), dysuria(-)

abd.strain(-) Incontinence Sx. : Coughing (+), Laughing (+), Running (-),

Weight bearing (-) Walking (-),Resting (-)

P.Ex Cystocele(-) Rectocele(-)

Sling operation(TVT) was done

--- postop. 1 mo.; leakage (-), frequency(-), urgency (-)

ISD 가 있는 SUI 환자의 수술적 치료로서

1.TVT (or SPARC) 를 사용하겠다 .2.TOT 도 상관없이 사용하겠다 .3.Pubovaginal sling 을 여전히

사용하겠다 .

향후