SURGERY FOR FEMALE STRESS URINARY INCONTINANCE

 General considerations

1.   Diversity on choice of surgical procedure. Burch colposuspensions/ fascial slings/ MUS/Injectables

2.  Indication should be significant loss of urine creating social or hygienic problem 

3. Most procedures aim to repositioning of bladder neck and urethra in a supported retropubic position. Others aim to provide increased urethral resistance by improving urethral coaptation.

 Preoperative considerations

1.   History taking, physical examination, laboratory testing and imaging. 

2. Thorough evaluation of all pelvic floor organs should be done preoperatively, In some cases full Urodynaemics studies may be indicated.

3.   Perioperative antibiotic treatment in the operating room.

4. General, regional, or local anaesthesia according to the procedure performed and patient condition

5.  Dorsal lithotomy positioning, prepping and draping the abdomen and vagina in a sterile fashion.

6.    Draining the bladder with a Foley catheter at the beginning of the procedures.

 Operative and postoperative general considerations when performing vaginal surgery

1.  Cystourethroscopy performed at the end of the procedure is recommended to verify that the bladder is intact, that no sutures are traversing the urethra or bladder, and that ureters are patent.

2. The vagina may need to be packed at the end of the procedure to facilitate hemostasis in some cases. Packing can be removed postoperative few hours to the next day.

3. Indwelling catheter or suprapubic catheter is left in the bladder in come cases and as when is needed.

 SUBURETHRAL SLING PROCEDURES (MUS)

1. Suburethral sling is a strip of material that is tunneled underneath the bladder neck and/or proximal urethra or midurethra and then attached to above structure such as rectus facia or pelvic sidewall to create a posterior support, or hammock effect to the bladder neck and proximal urethra.
2. Slings are used for all kinds of stress urinary incontinence including anatomical urinary stress incontinence(urethral hypermobility) and can be  completely transvaginally, or with combination of transvaginal and abdominal approach.
3. Sling materials include:
1. Autologous sling such as fascia lata or rectus abdominis, harvested at the time of surgery
2. Homologous material such as cadaveric fascia lata
3. Synthetic slings: Applied retropubically or transobtoratorly.
4. Minimally invasive sling procedures have been introduced including the tension free vaginal tape using polypropene tapes.

 Suburethral slings

• Transvaginal tape (TVT) is becoming popular choice as effective minimally invasive anti-incontinence surgery.
• Long term results of up to 17 years showed comparable objective and subjective cure rate as to Burch colposuspension.
• The Tension free vaginal Tape (TVT) is the only sling but that is put at the mid-urethra level. Hence, the name Transvaginal Tape (keeping the TVT abbreviation) was suggested.
• To reduce such complications, The transobturator approach (TOT). Initial results were comparable with TVT with minimal complications.

 Operative technique of TVT (Tension-free vaginal tape) & Transobturator apparoach (TOT)

• Positioning and preparation as in preoperative consideration for vaginal surgery.
• Local, regional, or general anesthesia can be used.
• Two 5mm long abdominal incisions are made 5cm apart just above the superior rim of the pubic bone (TVT). Small stab incision is made at the ischiopubic angle at the same level as the clitoris (TOT).
• A 1.5cm long vaginal wall incision is made over the midurethra, 1cm proximal to the external urethral meatus.
• Bilateral paraurethral dissection of vaginal wall is performed.
• A prolene tape attached on both ends to trocars/needles and covered by a plastic sheath is used. One of the trocars/needles is introduced and advanced through the vaginal incision, the urogenital diaphragm, and the retropubic space in close contact to the posterior aspect of the pubic bone until its tip is brought out to the abdominal incision. TOT has similar approach but the needles are introduced either through inside out as in TVTo or from out side in as other TOT’s.
• Using the trocar/ needles at the other end of the sling, this step is then repeated, on the contralateral side.
• Cystoscopy is performed to rule out bladder or urethral damage.
• Once bladder and urethral integrity have been verified, the trocars/needles on both sides removed and hence the tape is pulled all the way through the abdominal incision. The tape tension is further adjusted under the urethra.
• The plastic sheath covering of the tape is removed. The friction between the tape and the tissue canal created by the trocars serves to hold the sling in place with no need for additional suture fixation of the sling.
• Abdominal and vaginal incisions are closed.   

 Complications:

• Bladder perforation ( 5% with TVT, almost nil with TOT)
• Bowel Injuries ( 0.7/1000)
• vascular injuries ( 0.7/1000)
• Bleeding
• Voiding dysfunction (2.8% or 23/1000- 79/1000)
• Overactive bladder.
• Tape erosion/exposure ( <1%)

 

References

1. Transobturator tape for Stress Incontinence: North Queensland Experience NAidu A, Lim YN, Barry C et al . Aust N Z J Obstet Gynaecol. 2005 Oct;45(5):446-9

2. Does the MORNAC Transobturator sling cause post-operative voiding dysfunction? A prospective study. Barry C, Naidu A, Lim YN et al. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):30-4

3. Transobturator sub-urethral suspension, an approach worth changing to?.Malaysian Journal of O & G: 2005 ( Suppl)

4.  Transobturator Tape(TOT) procedure: The Ipoh Experience JUMMEC 2011;14(1)

http://jummec.um.edu.my/filebank/published_article/2967/JuMMEC%202011%2014(1)%2010-20.pdf

 5. Seventeen years' follw-up of the tension-free vaginal tape procedure for stress incontinence. Nilsson CG et al . Int Urogynaecol J 24(8)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MISSION ULAAN BAATOR, MONGOLIA

I had an opportunity to provide some training for young doctors & specialist in Ulaan Baator on OASIS & Urogynae update. A team of 4 urogynaecologist ( Me, Dr Ng Poh Yin, Dr Tan GI & Dr Ida Lily Waty) manage to organise & execute this valuable training.  It took us near full one day to reach Ulaan Baator, as there is no direct flights from KL. The Trip was co-organise by MUGS & Mongolian Urogynae society and Mongolian O & G society. During this trip we had lectures on OASIS & wet lab / hands on sessions with the mongolian trainees & specialist. The day 2 was mainly an update in Urogynaecology. The training was well accepted. We had nearly 40 doctors from different parts of Mongolia participated in the training.

Following the training course, we also had life time opportunity to explore deep part of Mongolia. It was vast & unexplored territory. 

Mongolia is a country sandwiched by Russia in the north & china in the south-east. It has vast steppe land. The total population is about 4 million & more than half of them live in Ulaan Baator (Capital of Mongolia). Mongolia was at one time a great country.  Genghis Khan is a great Mongol emperor who had conquered large part of Central Asia and China in  13 & 14th century.

          The Ulaan Baator City is a modern City. The Main hospital is well equipped and up to date.

                     The country has beautiful terrin. The people are super friendly and welcoming. 

Overall it was a great teaching & exploration trip for all of us

PERI-URETHRAL AND PERINEAL-VAGINAL MASSES: HOW TO DEAL WITH IT ?

Periurethral, perineal or vaginal  masses are masses or swelling around the urethral meatus, vaginal area or the perineal region. The incidence is less than 4%. The main presentation is feeling a swelling or mass around the meatus, vagina & vulva, difficulty in passing urine, urethral discharge and pain on sexual intercouse. There is limited information / literature on the exact incidence, diagnosis and management for this conditions.

periurethral mass

The differential diagnosis of suchs  massess include;

• Urethral Diverticulum ( 84%)
• Peri-urethral leiomyoma (7%)
• Periurethal vagianl cyst/ Gartner's cyst (6%) or remnant of mullerian duct cyst
• Skene's gland cyst or abcess
• Retention cyst
• Urethral Prolapse
• Urethral Caruncle
• Ectopic Ureterocele 
• Inguinal/Femoral Hernia
• Benign tumours- angiomyoblastoma, fibromas, warts
• Malignancies

The diagnosis is usually clinical, and some case we may need to do some imaging studies to see the nature & extent of the lesions. The suggested imaging studies include perineal Ultrasound, Ct Scan/ MRI, Urethroscopy/cystoscopy, micturating cystogram and double balloon urethrogram.

The management options will depends on the diagnosis. If small & asymptomatic, usually can be managed as conservatively. Aspiration of the cyst content can be done , but usually the cyst reoccurs. The suggested surgery include endoscopic re-roofing, trans-urethral incision, Marsupialization of the diverticulum or cyst, cystectomy of the cyst wall in cases of gartner's or skene gland cyst. Diverticulectomy in case of urethral diverticulum with grafting in some case. In some case excision of the lesions

Below are some of my personal collection of cases & how l managed them:

Case 1. 36 year old Para 2 with urinary incontinence & passing pus discharge urethral meatus. on examination noted tender, fluctuant mass, below urethral meatus. On pressing/milking the mass, pus & urine discharge noted coming from the urethral meatus. The diagnosis of Urethral Diverticulum was made. Marsupialization was carried out. This will create a small suburethral  fistula and allow the secretion to escape & thus facilitates the closure & healing of the fistula tract that communicates into the urethra. Based on my experience, this is very effective & simple operation.

suburethral abscess

Case 2. 32 year old patient presented with periurethral mass for 3 months. Initially the mass was small 3x 2 cm. Over few mass it become 8x8 cm. It was infected & rubbery in nature. Patient also had difficulty in passing urine. EUA & excision of the mass was carried out. The histology was consistent with para-urethral angiomyofibroblastoma. This case was published in Australia & New Zealand Continence Journal Vol 10, No 1, March 2004. The patient recovered very will with no recurrence. This condition is Benign tumour. 

Case 3. 29 year old Para1, noted cystic swelling around urethral meatus after delivery. On examination there was a cystic, transparent mass around 6 o clock below the urethral meatus. It was non tender mass. Mobile & cystic in nature. The options for such cases are neddle aspiration (but the recurrence rates are high), cystectomy, & marsupialization. In this case complete cystectomy was done. paraurethral or vaginal cyst develop as result of local irritation, inflammation or sequential blockage of vaginal or paraurethral glands. If infected the develop into abscess.

Case 4. 56 year old para 5 lady, presented with progressively enlarging mass on the left side of vagina. On examination the was 18 x 12 cm cystic mass noted. The mass was multiloculated & cystic. CT Scan showed cystic mass with no intra pelvic extension. A dignosis of  vagianl cyst/ Gartner's cyst or remnant of mullerian duct cyst was made. EUA and drainage was carried out. Serous like material removed and complete cystectomy and labioplasty was carried out. Vaginal wall cyst/ Gartner/ Mullerian remnant cyst occurs in 0.5-1% of patients. Mostly asymptomatic & unreported. An evaluation should include upper genito-urinary tract assessment to rule out any extension of the mass/cyst and other genito-urinary tract abnormalities. US/CT scan/MRI is the imaging modality of choice. If the is no concomitant abnormality of extension, than a cystectomy or marsupialization is surfice.

Case 5. 44 year old para 5 presented with recurrent left side tender vaginal mass. The mass typically present during pregnancy & subside after delivery. After the last childbirth, the mass persisted and become very tender & painful. Transabdominal ultrasound revealed a longitudinal mass from left vaginal wall extending to pouch of douglas. The mass was mixed in echogenicity. CT scan of abdomen reported as cystic mass anterior to the sacrum extending to lower part of vagina with possible differential diagnosis as (rectal duplication cyst or cystic sacrococcygeal teratoma or ischiorectal cystic lesion/abscess.). A diagnostic laparoscopy was carried out, which revealed left ischiorectal fossa abscess Therefore, 300cc of pus and caseous material drained through vagina. Pus culture and sensitivity grew B-hemolytic non A/B steptococcus. Otherwise, swab AFB, all other infective screening were negative. The fasting blood sugar was 4.8mmol/l. Sigmoidoscopy and Colonoscopy was essentially normal. This time a large marsupialization was done & the abscess was drained. Since than the mass/abscess did recurred. She remain asymptomatic until now.

Case 6. 68 year old patient postmenapausal for 20 year, presented with painful micturition and vaginal soreness. On assessment, there was a growth at the external urethral meatus. The common diagnosis for such conditions are Caruncle or urethral prolapse. In this case this patient had a urethral prolapse. Treatment for caruncle or prolapse is usually topical estrogen application. In some case caruncle/prolapse can be infected. in such cases antibiotics may be indicated. Surgical options includes cauterization for the caruncle or prolapse.  In some cases of prolapse, circumferential excision of the prolapse and approximation of the urethro-vagina margins can be carried out.

Case 7. 58 year old, presented with urinary obstruction & pv bleeding. 

On Examination, noted friable mass periurethrally. Biosy was consistent with sq cell ca stage 4. Patient was referred for radiotherapy. Malignancy at peri- urethral region is very rare. Prognosis is usually poor.

Case 8. This is a 15 year old girl, presented with continuous urine leakage from young. No proper previous evaluation. On examination, there was continuous leakage & wetness at periurethral region. CTU was carried out, revealed an ectopic ureter from right kidney extending to the periurethral region. Patient was referred to our paediatric surgeon, who subsequently ligated the ectopic ureter. Patient was symptom free after this procedure.

Case 9. A 6 year old child presented with difficulty in pass urine & para peri-urethrally. The mass was firm in consistency & non tender. It was reducible. An inguinal hernia was suspected. This patient referred to paediatric surgeons. The finding confirm reducible inguinal hernia with omentum

Case 10. A 58 year old patient presented with large mass, protruding from the vulval region. It was there for nearly 20 year. it was slow growing mass. On examination there was a firm & pedunculated mass on the left labia. It was non tender and mobile. US & CT scan did not show any extension or pelvic mass, Uterus & ovaries was normal, Labial Fibroma was diagnosed. Patient underwent excision with much problem. Histology was consistent with fibroma

Case 11. 65 year old para 5 presented with right side periurethral mass. the mas was firm & tender on pressure. Patient also had voiding difficulty. On examination there was a firm mass in the right upper labia and extending to lower abdomen. it was not reducible. A CT scan revealed a possible ovarian mass with omentum. A diagnosis of ovarian hernia was diagnosed. EUA & exploration was carried out, It turn of as ovarian fibroma prolapsing through the inguinal canal. Right Salphingo-oopherectomy & hernia repair was carried together with surgical team. Patient recovered well. Histology consistent with ovarian fibroma.

Other Mass that I have seen in my practice:

Recurrent mass at upper left labial. First excision biopsy was leiomyoma. came back again after 5 years, the second Excision Biopsy can as Leiomyosarcoma. She was subsequently referred for wider excision and chemotherapy with gynae-oncologist.

This patient presented as fungating grown & wary lesions. Biopsy & excision of the warty growth reveal Hyperkeratosis. Manged with local & systemic steroids. No under dermatology.

Hypertrophic clitoris. Patient planned for clitroplasty

 Genital Wart. Excision & cauterization of the wart carried out. Followed by application of  imiquimod cream.

Chronic Ulceration & necrotic mass. Biopsy revealed sq cell ca, Wide excision & radiotherapy carried out.

 Recurrent Paget's Disease . Now on remission & intermittent Imiquimod cream treatment.

Excessive Lichen sclerosis. Excision biopsy and local Steroid treatment given, recover very well.

 A baby with Ambiguous genitalia. given to paediatric surgeon to manage

 Case of Vulva Varicosity before & after ligation of the feeding vessels ( by Plastic Surgeon) newer modality is sclerotherapy and embolization technique by Interventional radiologist.

In Summary, In most case proper history & examination is sufficient to make a diagnosis. In some case we may want to take a biopsy before treatment or we can do an excision biopsy which is diagnostic and therapeutic, in which the lesion is removed at the same setting. We also may need some imaging modality like US/CT Scan or MRI or CTU / cystoscopy to assess the extend of peri-urethral, perineal or vaginal masses. These imaging will give us some idea about the relationship of such mass with the surrounding areas. This information is important to plan our definitive surgical plan.

All the photos were taken and displayed with patients permission.

Like to thank the owners of the drawings/ pictures as these photos were taken taken from google images. They were displayed here purely for teaching purpose only. 

Malaysian Urogynaecology Mission to Vientiane, Laos

A team of Malaysian urogynaecologists participated in a mission to Vientiane, Laos on the invitation of the officials from the Ministry of Health, Laos & The Obstetrics & Gynaecology society Of LOAS  . This team comprised Dato Dr Aruku Naidu ( Team Leader  from Hospital Raja Permaisuri Bainun, Ipoh), Dr Ng Poh Yin (Senior consultant urogynaecologist of Hospital Kuala Lumpur), Prof Lim Pei Shan (consultant urogynaecologist  from Hospital Universiti Kebangsaan Malaysia), Dr Ida Liliwaty Latar (consultant urogynaecologist from Pusat Perubatan Universiti Malaya), Dr Tan Gaik Imm (urogynaecology fellow from Hospital Pulau Pinang), Sr Tan Lee Khan (Hospital Kuala Lumpur) Sr Lee Fong Hoo (Hospital Kuala Lumpur). This mission was partially sponsored by the Obstetrics and Gynaecology Society Malaysia (OGSM), with the support of The Malaysian Urogynaecology Society (MUGS). 

       

 The team arrived in Vientiane on 28^th October and proceeded to work soon after arriving. The mission was held at the Women and Neonate Hospital Vientiane. This was the first and only Maternal & New born Hospital in Laos.  After a quick tour of the hospital premises and facilities, the team proceeded to assess women with urogynaecological problems, who had been screened beforehand by the local hospital doctors. Out of 10 women was reviewed, but only 3 patients were identified for surgical intervention, including 2 women with advanced Stage 4 pelvic organ prolapse and 1 patient with  3^rd degree tear repair with bad wound dehiscence.

The following day, the Malaysian team conducted the Obstetric Anal Sphincter Injury (OASIS) Workshop for the benefit of the local obstetric specialist and registrars. This workshop was attended by 60 participants. They were junior doctors and specialist from all over Laos. The workshop comprised lectures delivered by the mission urogynaecologists. The topics discussed include pelvic and anal sphincter anatomy, risk factors and prevention of OASIS, and methods of repair of OASIS. The lectures were delivered with the help of a local translator. The afternoon was spent on a hands-on workshop using life animal models & life porcine specimen. The participants had the invaluable opportunity to practise their skills in the repair of the anal sphincter tears on sow perineum.

On the 31 October 2017, the team performed pelvic reconstructive surgeries on the 3 patients who had been identified and prepared for surgery. Two teams of Dr Ng/ Dr Ida and Dr Aruku/ Dr Lim performed the surgeries which included vaginal hysterectomy, pelvic floor repair, McCall culdoplasty and perineal body reconstruction. The aim of the surgical workshop was not only to offer symptom relief to the patients but also to demonstrate surgical techniques and train the Laotian doctors in repair methods, and this was aptly demonstrated by the team. The nursing team of Sr Tan and Sr Hoo were also able to educate the local nurses on the proper technique to safely assist and sterilize equipment for the operation.

 

On the final day of the mission, the team visited the hospital to conduct a post operative ward round to ensure that the patients were on the road to an uncomplicated recovery. We found that the 3 patients were nursed in the recovery area of the operating theatre. Although somewhat uncomfortable for the patients, this enabled them to have better monitoring in the critical post operative period due to logistic reasons in the local setting. All 3 patients were recovering well, and we educated the local registrars about post operative management for urogynecology patients, which included pain relief, prevention of thromboembolism, catheter care and the trial of void protocol and follow up. As with the common problems with mission such as this, the importance of post operative care cannot be overemphasized as the team cannot be present onsite throughout the entire recovery period and also to assess patients in the immediate and short term post operative period, which would be the ideal situation. We however ensured that the local doctors would be able to contact the operating team for advice should the need arise so as not to compromise patient care.

Overall it was a very successful inaugural mission to Vientiane for both the Malaysian and Laotian teams. We were able to build networks and learn from one another. It was enlightening to experience working in a different country’s settings with challenging logistics, manpower, experience and equipment. We hope to assist our foreign counterparts in setting up and running an organized urogynaecology service by periodical missions over the coming years and hope to foster goodwill and better friendships for future collaboration within the Asia-Pacific region.

Last but not least, the Malaysian urogynaecology Mission Team likes to thank all the team players for their valuable support either morally or physically. A very big thanks to OGSM for the timely partial financial support to make this event a successful event.