Overview ofStress Urinary Incontinence &

Minimally Invasive Slings

Ken Maslow, M.D.Urogynecology and

Reconstructive Pelvic Surgery

Assistant Professor Department of Obstetrics & Gynecology

University of Manitoba

Etiologies of UI

• SUI – Stress UI• UUI – Urge UI (OAB)• Mixed UI• Functional UI (DIAPPERS)• Overflow UI• Other

– Fistula, ectopic ureter, urethral diverticula

• Uncategorised Incontinence

ICS SUI Definitions• Symptom

– Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing

• Sign– Observation of involuntary leakage from the

urethra, synchronous with exertion/effort, or sneezing or coughing

• Diagnosis– Urodynamic SUI: involuntary leakage of urine

during CMG with increased abdominal pressure, in the absence of a detrusor contraction

SUI: Mechanism

SUI Treatment• Behavorial

– Lose weight (Level 1)

– Timed toileting/↓ intake (1a)

– Treat constipation– Stop smoking (cough)– Avoiding high impact

activities/heavy lifting– Kegels (Level 1)

• ± biofeedback

• Non surgical– Pessary

• (Level II-III)

– Meds• Imipramine

– Not very effective

• Duloxetine– Not available

• Surgical

Kegels / PFMT

• Level 1 evidence effective for SUI Tx

• Ensure Pt contracting correct muscles

• No one program recommended– 3-5 sec squeeze, 10-20 cont/3-5 x per day – Addition of biofeedback, vag cones, or electrical

stimulation no benefit– However in Pt who do not isolate correct muscles,

may be benefit of biofeedback devices

• Pelvic floor physiotherapist

Vaginal PessariesVaginal Pessaries

Surgical Tx SUI• Anterior colporraphy

– Kelly plication suture

• Needle suspension procedures– Stamey, Raz, Pereyra, Gittes

• Retropubic urethropexy– Burch, MMK

• Suburethral Sling procedures– Traditional Slings, Minimally invasive midurethral slings

• Periurethral bulking procedures• Artificial Sphincter

Burch Procedure

Midurethral Slings

Suprapubic Approach

Obturator Approach

Transobturator tape (TOT)

Midurethral Sling• Day surgery• 10-20 minute procedure• IV Sedation & local freezing• Requires 1-2 weeks off work• Complications Rare

– Bleeding, infection, voiding dysfunction, mesh erosion, de novo/worsening UUI

– TVT: bladder/bowel/lg vessel injury– TOT: vaginal perforation, leg/groin pain

• Efficacy– 90% cure at one year– Comparable to Burch at 2 yrs F/U (RCT: Ward 2004)

“Mini – Sling”TVT SECUR System

Summary• SUI is a common problem in women• Conservative Tx

• Kegels, weight reduction, pessary, (meds)

• Surgical Tx• Minimally invasive mid urethral slings

– Day surgery– Quick recovery– Little risk– Good outcome

Ken MaslowUrogynecology & Reconstructive

Pelvic Surgery

St. Boniface ACFPh: 237-2713Fax: 237-2284