DR LOPEZ FONTANA RODRIGO
CATEDRA DE UROLOGIA
UNC
20-40% DE LAS MUJERES SUFREN IO:
50% ESFUERZO
4-10% REQUIEREN CIRUGIA
COSTO ANUAL: $16 BILLONES
ALTERACION CALIDAD DE VIDA, RESTRICCIONES SOCIALES Y ALTERACIONES MEDICO-HIGIENICAS
CONSERVADOR: mejora pero NO CURA
QUIRURGICO
Howard A Kelly (1913)
Plicatura de la fascia
vesicovaginal: EXITOS 40 a 60%
Colporrafia anterior
Cistouretropexiasuprapúbica (1949)
Marshall VF, Marchetti AA, Krantz KE.The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet. 1949;88:509–518.
J. Burch (1961)Curación del 85%
Burch JC. Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol. 1961;81:281–290.
Gold standard
Alcalay M, Monga A, Stanton SL. Burch colposuspension: a 10–20 year follow-up. Br J Obstet Gynaecol 1995;102:740–745
Eriksen BC, Hagen B, Eik-Nes SH, et al.Long-term effectiveness of the Burch colposuspension in female urinary stress incontinence.Acta Obstet Gynecol Scand. 1990;69:45–50.
PERO…2-3 DIAS DE INTERNACION4-6 SEMANAS DE REPOSO
Liu 1993Liu reported the first large series; 132patients were followed for 3 to 27 monthswith a 97% cure rate
Liu CY. Laparoscopic treatment of genuineurinary stress incontinence. Clin Obstet Gynecol.1994;8:789–798.
Vancaille 1991
1907 Von Giordano músculo recto interno del muslo
1910 Goebell piramidales
1917 Stoeckell aponeurosis
1942 Albridge fascia
1978 McGuire & Lytton Abordaje combinado
Autólogos: 85 % de éxito
Aldridge AH. Transplantation of fascia for the relief of urinary incontinence. Am J ObstetGynecol. 1942;44:398–411.
Jarvis GJ. Surgery for genuine stress incontinence.Br J Obstet Gynaecol. 1994;101:371–374.
Bidmead J, Cardozo L. Sling techniques in the treatment of genuine stress inconti-nence. Br J Obstet Gynaecol. 2000.
„„hammock theory” [Delancey, 1994; Delancey and Sshton-Miller, 2004]
“Integral theory‟‟[Ulmsten, 1990]
DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713–30.
Función normal - disfunción
Orientar la corrección sitio-específica
Bases anatómicaspara explicar:
Teoría Integral
Petros PE and Ulmsten U. An Integral Theory of Female Urinary Incontinence. Acta Scand O&G. 1990
Soporte inestable
From DeLancey JO.Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994
Pubis
UArcoTendíneo
Elevador
Vagina
LigamentoPubo-uretral
LigamentoUretro-pélvico
Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory procedurefor treatment of female urinary incontinence. Scand J Urol Nephrol 1995;29:79–82.
Mallas de Polipropileno
Monofilamento +75 m Multifilamento
Winters JC, Fitzgerald MP, Barber MD. The use of synthetic mesh in femalepelvic reconstructive surgery. BJU Int 2006; 98:70–76.Comprehensive review of the treatment of incontinence and prolapse using meshmaterials.
Ankardal M, Heiwall B, Lausten-Thomsen N, et al. Short- and long-term resultsof the tension-free vaginal tape procedure in the treatment of female urinaryincontinence. Acta Obstet Gynecol Scand 2006; 85:986–992.
Bladder
Nilsson 7 años de seguimiento: EXITO 80 a 85%
Rezapour M, Ulmsten U.EXITO 95%
Nilsson CG, Falconer C, Rezapour M. Seven-year follow-up of the tensionfreevaginal tape procedure for treatment of urinary incontinence. ObstetGynecol 2004; 104:1259–1262.
Rezapour M, Ulmsten U. Tension-free vaginal tape in women with mixedurinary incontinence: a long-termfollow-up. Int Urogynecol J 2001;12(Suppl 2):S15–S18.
GOLD STANDART
Resultados similares después de 2 años(Nivel de Evidencia 1)
2nd International Consultation on Incontinence 2001
Ward KL, Hilton P. A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up. Am J Obstet Gynecol 2004;190:324-31
Abouassaly R, Steinberg JR, Lemieux M, et al. BJU Int 2004; 94:110–113.
Fourie T, Cohen P.Int Urogynecol J 2003; 14:362–364.
Leboeuf L, Mendez L, Gousse A. Urology 2004; 63:1182–1184.
Zilbert A, Farrell S.Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:141–143.
Deng DY, Rutman M, Raz S, et al. Neurourol and Urodyn 2007; 26:46–52.
Vasculares Viscerales Hematoma Erosión Infección Obstrucción Disfunciones miccionales
vv.epigástricos
vv.obturatorios
vv.ilíacos
Malla
Vaginal
Uretral
Vesical
Subvaloración de
distopías pré-op
Tensión exagerada
sobre la uretra
Estenosis secundaria
a la erosión / infección
Complicaciones Funcionales (obstrucción)
Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001
Emmanuel Delorme 2001: VENTAJAS
No es necesaria Cistoscopía?
Evita el espacio de Retzius
Menores síntomas irritativos
Menor índice de disfunción miccional
Seguimiento 1 año: Cura del 90.6%
Delorme E, Droupy S, de Tayrac R, et al. Transobturator tape (Uratape): a newminimally invasive method in the treatment of urinary incontinence in women.Prog Urol 2003; 13:656–659
Forame
Obturatriz
Nervio, arteria y
Vena obturatriz
Trayectoria dela Aguja
N
A
V
Efectividad ligeramente < en TOT (ns)
Complicaciones (vesicales) < TOT
Trastornos del vaciado < TOT
Erosión de malla o perforación vaginal mayor en TOT (ns)
Dolor en ingle mayor en TOT
Urgencia De novo =
No diferencia significativa en pérdida de sangre, perforación vesical (TVT 0.7%, TVT-O 0%), y vaginal(TVT 1.5%,TVT-O 2.3%).
La única diferencia significativa fue el dolor inguinal (16% TOT vs 1.5% en TVT)
+ 0-5%
+ 5%
+ 3-15%
+ 10%
+ 10%
Morey AF, Medendorp AR, Noller MW, et al. Transobturator versus transabdominal mid urethral slings: a multiinstitutional comparison of obstructive voiding complications. J Urol 2006; 175:1014–1017
TOTTVT
Mellier G, Mistrangelo E, Gery L, et al. Tension-free obturator tape (MonarcSubfascial Hammock) in patients with and without associated procedures.
IntUrogynecol J Pelvic Floor Dysfunct 2007; 18:165–172.
TOT asociado a cirugía reconstructiva pelviana
Tipo de pte
Antec quir.
Vía de abordaje
Tipo de incont.
Complicaciones
Experiencia
Duración
Hospitalización
Cirugías asoc.
Costos
Mejor Resultado
Beneficio
Pte