do i need a multidisciplinary approach in lutd? · 2015-07-02 · do i need a multidisciplinary...

Do I need a multidisciplinary approach in LUTD?

Dirk De Ridder, MD, PhD, FEBUJan Deprest, MD, PhD

Pelvic Floor UnitKU Leuven

Diclosures

• Consultant, speaker, investigator for and someunconditional research grants from

– Astellas - Axionics

– Medtronic - Pfizer

– Laborie

– Allergan

– AMS

– Bard

Do you work with a multidisciplinary team?

• 1. Yes

• 2. No, I do not need it

• 3. No, but I would like to

Who is in your team ?

• 1. Uro and Gyne

• 2. uro and gyne and colorectal

• 3. uro and gyne and colorectal and physio

• 4. uro and gyne and colorectal and phsyio and others

• 5. other configuration than above

78% sling procedures performed by urologists

OBGyn perform twice more Prolapse surgery compared to Uro.

Reasons for non-collaboration

• “I am the best”

• There is no evidence that a combined approach improves outcome

• Financial reasons

• Competition for procedures (sling, laparoscopic promontofixation)

It can be lonely at the top!!

Reasons to collaborate

• Complementary knowledge and experience and skills can be offered to the patient in a comprehensive way

• Larger patient population

– Screening population gynecologists

• Scientific support and exchange

• Medicolegal aspects

• Expansion of therapeutic armamantarium

Complementary skills

PATIENT

Functional Urology

- urodynamics- neurogenic bladder- OAB- Ureteral surgery- Interstitial cystitis- Reflux

Gynecology

- Prolapse- Cervical pathology- Hormonal therapy- Endometriosis- Dyspareunia

Gastro-enterology

Colorectal surgery

- Constipation- Transit problems- Fecal incontinence- Rectal prolapse

Indications for PF team• Multicompartimental problems

– Prolapse with or without incontinence

• Significant comorbidities– Incontinence and/or prolapse with

• Diabetes• Neurological diseases ( Parkinson, dementia…)• Severe constipation

– Urinary and fecal incontinence

• Failed previous surgery or complications– Trying to avoid medicolegal consequences

• Extensive counseling• Team approach

• Discrepancy history, clinical and technical data

Urogynecologist / PF specialist?

• Pelvic organ prolapse

• Stress incontinence

• Urge incontinence

• Urinary diversion

• Urethral surgery

• Neuromodulation

• Colorectal problems

• GI motility

• How to reach sufficient numbers of patients to train and to maintain skills ?

• How to keep on top of evolutions in all the fields concerned?

Advantages of collaboration• Urologists and gynecologist team up

– Sufficient patient numbers guaranteed even in smaller centers

– Each specialist can import new approaches from his own specialty

– Cost cutting• Nursing staff, administration…

– Shared training opportunities

– “Peer” exchange

– Participation in multicenter trials

Gynecology

55%

Urology

40%

Colorectal

5%

Monodisciplinary assessment

Urodynamics Imaging Micturition chart Others

Multicompartimental problem

Multipathology

- fecal and urinary

- incontinence+ prolapse

MonocompartimentalMonosymptomatic

Monodisciplinary R/Multidisciplinary assessment

Monodisciplinary R/ by most appropriate team member

OR

Multidisciplinary surgery

Leuven Pelvic Floor Team 2015UROLOGY

Prof. D. De RidderDr. M. TutoloProf. F. Van Der Aa

GYNECOLOGY

Prof. J. DeprestDr. S. Housmans

IMAGING

Dr. D. Van BeckevoortProf. R. Oyen

GASTRO-ENTERO

Prof. G. Coremans

COLORECTAL SURG.Prof. D’HooreDr. A. Wolthuis

Clin

ical te

am

Su

pp

ort

PHYSIOTHERAPY.Prof. Van KampenDr. A. De Vreese

CONTINENCE NURSES

C. Guldemont M. Vanhasselt

Scie

ntific

team

IMPLANTS

Dr. M. KonstantinovicIr. Y. Ozog

NEURO-URO

Dr. T. GevaertDr. Y. DeruyverDr. F. Van Der AaDr. E. Weyne

N=21

ELECTROPHYSIOL.Dr. F. Bruyninckx

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008totaal 48 100 79 187 220 228 278 313 332 366 401 419 419 443urogyn 48 53 47 117 132 130 148 177 193 212 226 219 237 248multidisc 0 8 15 30 61 60 85 88 99 80 100 91 127 128neuro 0 47 32 70 88 98 130 136 139 154 175 200 182 195

0100200300400500600

NIncontinentie ingrepen 1995 - 2008

Setting up a team

TRUST Common goal

=

quality improvement-diagnosis-conservative treatment-surgical treatment-dealing with complications

Written agreement

Common decision tree

- The team- Infrastructure- Meeting organisation and logistics- Patient Centred Clinical decision making

- Who to discuss- Patient-centred care- Clinical decision making process

- Team Governance

Levels of collaboration

Joint meetings

Joint outpatient clinics

Multidisciplinary operations

Integrated team

Common decision tree

TrustCommunication

Exchange ofpatients

Business unitFinancial agreement

Com

plex

ity

Evolution of multidisciplinary surgery

The General urologist/gynecologist

The expert urologist/gynecologist

The teamplayer

UniversitätsklinikumErlangen


K. E. Matzel

Section Coloproctology, Department Surgery,

University Erlangen

.Global Congress on Lower Urinary Tract Dysfunction

Rome, 25.06.2015

Do I need a multidisciplinary approach in LUTD ?



K. E. Matzel

Section Coloproctology, Department Surgery,

University Erlangen

.Global Congress on Lower Urinary Tract Dysfunction

Rome, 25.06.2015

Do I need a multidisciplinary approach in LUTD ?

A colorectal surgeons view


Spatium vesico-vaginale

Spatium urethro-vaginale Spatium recto-vaginale

Bladder

Urethra

Rectum

Vagina

Anal canal

Pelvic organs

Anatomie des weiblichen Beckens

Coronal

Courtesy

Th. Wedel

Kiel


Pubis


Pelvic floor descent

Pathologies

Courtesy

Th. Wedel

Kiel


+Bladder

w/ cystocele

Rectum

w/ rectocele

Pubis


Pelvic floor descent

Pathologies

Courtesy

Th. Wedel

Kiel


No doubt the problem exists !

And it has an impact on QoL !

Multicompartment : Multidisciplinary


Increased understanding of dorsal

compartment functional disorders

Limited understanding of interaction of

the three compartments, both in healthy

and in patients

Multicompartment : Multidisciplinary


Constipation

Incontinence


Predictors of accidental bowel leakage


Survey response rate 63% (1869/2979), 45y-84y

DI : 35.4 % QoL worse

UUI: 4.3: OR: liquid IC (95% CI 2.4-7.9)

1.6: OR: solid IC (95% CI 0.5-4.9)

2.4: OR: flatal IC (95% CI 1.5-3.8)

FI: 5.8: OR: UUI (95% CI 1.9-18.2)


Incontinence vs Constipation !

Incontinence & Constipation ?

Wijffels NAT et al. lColorectal Dis. 2012 epub Jul 23.


Colorectal Dis. 2012 epub Jul 23.

Fecal incontinence: 56%

Incomplete evacuation: 45%

Straining: 34%

Digital assistance: 34%

Repetitive toilet visits: 33%


Colorectal Dis. 2012 epub Jul 23.

Evacuatory disorders: 74%

Fecal incontinence: 56% 1 out of top 1: 56%

Incomplete evacuation: 45% 1 out of top 2: 84%

Straining: 34% 1 out of top 3: 90%

Digital assistance: 34% 1 out of top 4: 94%

Repetitive toilet visits: 33% 1 out of top 5: 94%


URINARY OBSTRUCTION

OBSTRUCTEDDEFECATION

FECAL INCONTINENCEORGAN

PROLAPSE

URINARY INCONTINENCE

Pelvic Organ Dysfunction


Rectocele & Intussusception


Rectocele & Intussusception

Incomplete bowel emptying

Digital help for complete

evacuation

Lump in the vagina

Backache

Asymptomatic (~ 70%) !

UniversitätsklinikumErlangen* Pescatori M., Osp Ital Chir 2002


Pescatori M et al. Colorectal Dis. 2008, 785-9


Three major advances and challenges

1996: Dynamic MRI

1994: Sacral nerve stimulation

1999: Ventral mesh rectopexy


26%

0,7%2,8%

4,5%5%

Defecography findings in ODS: dorsal compartment

0,7%

UniversitätsklinikumErlangenAttenberger UI et al. Abdominal Imaging 2015, epub

Value of dynamic MRI in interdisciplinarytreatment of pelvic floor dysfunction


32%: Change of management

N:3: Surgery to conservative

N:4: Conservative to surgery

N:12: Surgical strategy


Evaluation

EAUS +/- other

tests

From conservative

Sphincter

defect

SNS Inject.Colostomy

ACE

Persistent fecal

incontinence

No

Sphincter

defect

Novel therapies

under evaluation:

PTNS

Mag. Sphincter

Slings

ABS

Stimulated

graciloplasty

first line second line

Madoff, Laurberg, Lehur, Matzel, Mellgren, Mimura, O‘Connell, Varmaproposed ICI Guidelines 2012

Sphincter-

oplasty


Sphincter

RepairSNS PNTS Inject-

ables

Numbers

Spectrum of

indication

Coexisting

pelvic

pathologies

Efficacy:

Short term

Long term

Surgical Options


Study (reference no.) No. patients Main indication Improvement > 50% Follow up(months)

Leroi 6 (5 with DI) FI 100% for FI 350% for urge UI0% for stress UI

Ganio 16 (8 with DI) FI 100% for FI 15100% for urge UI100% for stress UI

Uludag 50 (18 with DI) FI 96% for FI 1250% for UI

100% for stress UIAltomare 16 (4 with DI) FI 1/2 for urge UI 14

2/2 for stress UIEl-Gazzaz 24 DI FI and UI 31.8% for DI 29.5

13.6% for FI only18.2% for UI only

Haddad 33 children Neurogenic UI and/or 81% for UI 15(19 with DI) FI with congenital 78% for FI

malformation

Fi, faecal incontinence;UI.urinary incontinence .

Leroi Colorectal Dis. 2011;13 Suppl 2:15-8

SNS for Double Incontinence


• only 8 patients (21.6%) reported no improvement in either urinary or fecal incontinence

37 Ptswith DI

7 Pts with DI improved

Main Indication

group A

15 Pts UUI

group B

22 Pts FI

Success rate UUI: 80%

F/U: 28.4m

Success rate FI: 86%

F/U: 31m

11 Pts with DI improved

Total DI success rate: 48.7% (18/37)

SNS for Double Incontinence

Caremel, Chartier-Kastler, Leroi et al: Urology 2011


Constipation

Incontinence


Resection vs. Suspension


D'Hoore et al., Br J Surg 2004 & 2008

Ventral Rectopexy


Faucheron et al, Dis Colon Rectum 55, 660-5, 2012

Ventral Rectopexy


Procedure n %

Hysterectomy 154 39.1

Cystopexy 36 9.1

Rectopexy 19 4.8

Delorme / Altemeier 8 2.0

Cesarian section 15 3.8

Sphincterrepair 4 1.0

Gynaecological procedures 4 1.0

Colectomy 3 0.8

Kidney transplantation 1 0.3

Prostatectomy 1 0.3

Total 168 41.5 %

vRp, Status after...

D'Hoore et al., DGK 2013


Ventral Rectopexy: Evolution of indications

Full thickness rectal prolapse

Internal rectal prolapse (Intussusception)

Combined pathologies:

Enterocele ± rectocele ± vaginal

prolapse

UniversitätsklinikumErlangenWahed et al, Colorect Dis 13, 1242-47, 2011

Ventral Rectopexy: Constipation

All patients

Rectal prolapse


Symptomatic rectocele

Vaginal vault prolapse

Ventral Rectopexy: Constipation

Wahed et al, Colorect Dis 13, 1242-47, 2011


Corrects rectal prolapse syndrome

Safe and reproducable

Reconstruction of anatomy

Improvement of FI (80%)

Improvement of defecation (70%)

Avoids de-novo constipation

Ventral Rectopexy


Year

No

Ventral rectopexies in France

Ventral Rectopexies: Acceptance


VMR VMR


Challenges

Impact of interventions on neighboring

compartments remains unclear

- Extent of morphological changes

- Its correlation with functional changes


URINARY OBSTRUCTION

OBSTRUCTEDDEFECATION

FECAL INCONTINENCEORGAN

PROLAPSE

URINARY INCONTINENCE

Pelvic Organ Dysfunction


Diagnostics & Treatment

Directed by predominant symptoms

? Combined vs. sequential ?


Cases


Thank you

do i need a multidisciplinary approach in lutd? · 2015-07-02 · do i need a multidisciplinary...

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