Upload File

sling failures jerry g. blaivas, md clinical professor of urology weil-cornell medical center...

  • Home
  • Documents
  • Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
51
Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Upload: dalton-cooke

Post on 14-Dec-2015

223 views

Category:

Documents


3 download

Report

Tags:

TRANSCRIPT

Page 1: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Sling Failures

Jerry G. Blaivas, MDClinical Professor of Urology Weil-Cornell Medical Center

Adjunct Professor of UrologySUNY Downstate Medical Center

Page 2: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 3: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 4: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

• Clinical:– De-novo symptoms

• Weak stream• OAB• negative Q-tip angle

• Urodynamics:– High detrusor pressure / low flow:

pdetmax > 20 cm H20Qmax < 12 ml/S

– Blaivas Groutz nomogram

Urethral Obstruction

Page 5: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

- 45O

Page 6: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

MSCO

MSCO

High pressure (pdetmax = 75)

Low flow (0)

Page 7: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Blaivas - Groutz Nomogram

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50Free Qmax (ml/ sec)

pdet

.max

(cm

H2O

)

Moderate obstruction (2)

Severe obstruction (3)

Mild obstruction (1)

Unobstructed (0)

Blaivas & Groutz, Neurourol & Urodynam 19:553-564, 2000

Page 8: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Rx of Post op Urinary Retention

• Depends on type of sling• Initial Rx intermittent

catheterization• Synthetic sling

• early intervention days – weeks

• Autologous slings• Delayed intervention – months

Page 9: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Rx of Post op Urinary Retention

• ? Need for further workup

• Q-tip

• cystoscopy

• urodynamics

Page 10: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Surgical Rx of Sling Obstruction

• Sling incision• midline• lateral

• Urethrolysis• antero-lateral• circumferential • +/- Martius flap

interposition• Technique determined intraop

Page 11: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 12: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 13: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 14: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

N Type Success % SUI %

Nitti, et al 19 Midline Incision 84% 17%

Amundsen, et al

32 Various 94% 9%

Goldman,et al

14 Midline Incision 93% 21%

Sling Incision Results

Nitti et al. Early results of pubovaginal sling lysis by midline sling incision. Urology 2002.

Amundsen et al. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J Urol. 2000.

Goldman et al. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 2003

Page 15: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 16: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 17: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 18: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 19: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 20: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Circumferential Urethrolysis

Page 21: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 22: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 23: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 24: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 25: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 26: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethrolysis

• Vaginal

• Supra-meatal

• Retropubic

Page 27: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethrolysis Results

N Type Success % SUI (%)

Foster & McGuire48 Transvaginal 65% 0%

Nitti & Raz 42 Transvaginal 71% 0%

Cross, et al 39 Transvaginal 72% 3%

Goldman, et al 32 Transvaginal 84% 19%

Petrou, et al 32 Suprameatal 67% 3%

Petrou & Young 12 Retropubic 83% 18%

Carr & Webster 54 Mixed 78% 14%

Page 28: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 29: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 30: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Bladder neck

Bladder neck

Eroded mesh

Page 31: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

VLPP

Page 32: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 33: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Treatment of Erosions.

• remove as much of sling as possible

• closure of the urethra

• +/ - urethral reconstruction

• +/ - biologic sling

• +/ - Martius flap

Page 34: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Too Tight

• Urethral obstruction

• Detrusor overactivity

• Erosion

• Devascularization > recurrent SUI

Page 35: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 36: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Too Loose

Intrinsic sphincter deficiency

Urethral hypermobility

Recurrent sphincteric incontinence

Page 37: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

VLPP

AGAGAG

VLLP = 92 cm H20Qtip = 0 > 60O

Page 38: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

AG

Page 39: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

JK

VLPP = 42 cm H20Q tip = 0

Page 40: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
Page 41: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Treatment of Recurrent SUI

• no compelling data

• for hypermobility, surgeon choice

• for poorly mobile or pipe - stem urethra, biologic bladder neck sling

Page 42: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 43: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Wrong Position

• Too far proximal – persistent sphincteric incontinence

– urethral obstruction– ureteral injury

• Too far distal – persistent sphincteric incontinence

– urethral obstruction

– urethral hypermobility

Page 44: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

MS

VLPP = 35 cm H20

Sling proximal to BN

Page 45: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

sling

Page 46: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

MSCO

High pdet

No flow

Page 47: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

MSCO

Page 48: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

MSCO

Page 49: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Why Do Operations Fail?

• Too tight

• Too loose

• Wrong position

• Detrusor overactivity

–De-novo

–Persistent

• Erosion

• Wrong indication

Page 50: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Wrong Indication• Urinary fistula mistaken for

sphincteric incontinence

• Overactive bladder mistaken for sphincteric incontinence

• Sine-qua-non - Never operate on stress incontinence without actually diagnosing sphincteric incontinence with your own eyes

Page 51: Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Conclusion• Complications & failures after

incontinence surgery are not uncommon

• Early evaluation to rule out remediable causes should be undertaken– UTI– Urethral obstruction – sling erosion– foreign body

• A successful outcome is likely in the majority of patients


FETAL & WOMEN’S IMAGING · Harvard Medical School Boston, Massachusetts Mark P. Cain, MD Professor of Pediatric Urology University of Washington Co-Chief of Pediatric Urology Seattle

Emergency in Urology Dr. Abdelmoniem Eltraifi Consultant Urologist & Clinical Ass. Professor

WELCOME NEW FACULTY! Kusmartsev PhD Assistant Professor Department of Urology Paul Crispen, MD Associate Professor Department of Urology Paul Dominguez-Gutierrez, PhD Post Doctoral

Urology and Gynecology - Springerstatic.springer.com/.../application/pdf/Gynecology+Urology+DS.pdf · Urology and Gynecology Results Matter. ... Springer’s Urology & Gynecology

Robotic Cystectomy – Role in 2017 · Robotic Cystectomy – Role in 2017 Dipen J. Parekh . Professor and Chairman, Department of Urology, Victor A Politano Endowed Chair in Urology,

Acquired Disorders of Spermatogenesis By Paul J. Turek MD, Emeritus Professor and Endowed Chair in Urology Education, Department of Urology, University of California San Francisco

perineocon.comDr Bassem S Wadie Mansoura University, Mansoura, Egypt Prof (Dr) Jerry G. Blaivas Weill Cornell Medical College, USA Dr Kurt A. McCammon Urology of Virginia, USA Dr Victor

GENDER DYSPHORIA AND REASSIGNMENT James M Cummings Professor, Division of Urology University of Missouri

Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of Urology Eric Savitsky, M.D. Associate Professor Department

Jaime Landman Professor of Urology and Radiology … Manual/8.Landman... · Professor of Urology and Radiology Chairman, Department of Urology ... UC Irvine Medical Campus . 10

Robotic & Laparoscopic Urology & Paediatric Urology...Robotic & Laparoscopic Urology & Paediatric Urology Institute of Clinical Medicine / Department of Urology & Paediatric Urology,

Pediatric Urology Emergencies Ahmed Al-Sayyad MD,FRCSC Assistant Professor-King Abdulaziz University

5TH INTERNATIONAL TECHNO-UROLOGY MEETING (TUM) · Giorgio Scagliotti Professor Of Oncology At The University Of Torino, Italy ... Cesare Scoffone Head Of The Department Of Urology

Urethrovaginal Fistula & Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor

JEFFERSON UROLOGY IN REVIEW 2010 urology in review 2010 . ... jefferson university hospitals drop anchor at philadelphia navy yard . ... david m. davis visiting professor”

The Gold Standard: Autologous Fascial Pubo-Vaginal Sling Jerry G. Blaivas Clinical Professor of Urology Joan & Sanford Weil Medcial School Cornell University

Urology Products - Advin Urology

Urethral Reconstruction Jerry G. Blaivas, MD Clinical Professor of Urology New York Hospital Cornell Medical Center Adjunct Professor of Urology SUNY-Downstate

The Milton and Carroll Petrie Department of Urology · 3 Other keynote presenters included: • Inderbir S. Gill, MD, Chair and Distinguished Professor of Urology at the Keck School

Evaluation of Lower Urinary Tract Symptoms (LUTS) Jerry G. Blaivas, MD Clinical Professor of Urology Weil-Cornell College of Medicine Adjunct Professor

Ihor S. Sawczuk, M.D. PROFESSOR & CHAIRMAN UROLOGY TOURO UNIVERSITY COLLEGE OF MEDICINE ADJUNCT PROFESSOR OF UROLOGY COLLEGE OF PHYSICIANS & SURGEONS

Urology SURG 451Clinical session Dr. Danny M. Rabah Associate Professor Chief of Urology, KKUH, KSU

Department of Urology Upstate Medical University Syracuse, NY bratslavski b.pdf · Gennady Bratslavsky, M.D. Professor and Chairman Department of Urology Upstate Medical University

CURRICULUM VITAE Sanjay Gupta, Ph.D., M.S. · Sanjay Gupta, Ph.D., M.S. Professor of Urology Carter Kissell Endowed Chair in Urologic Oncology Department of Urology Case Western Reserve

UCLA Urology · Z. Chad Baxter, MD, UCLA Urology assistant professor and a specialist in female pelvic medicine and reconstructive surgery, offers the MonaLisa Touch treatment at

G. Pourmand MD. Professor of Urology Urology Research Center, Sina Hospital Tehran University of Medical Sciences, Iran Tehran University of Medical Sciences

EPCA: A silver lining for early diagnosis of prostate cancer GHOLAMREZA POURMAND, MD Professor of Urology Urology Research Center Tehran University of

Common Problems in Urology… and new solutions! Greene... · 2014. 10. 16. · 1 Common Problems in Urology… and new solutions! Kirsten Greene, MD, MS Associate Professor and Vice

Uro-Health Clinic fileDr. Divakar Dalela MBBS, MS (Surgery), MCh (Urology), FICS (Urology), FAMS (Urology) Consultant Uro Surgeon Professor & Former Head Dept. of Urology, KG Medical

TRY for DRY Healthcare Training Instructor Max Maizels, MD Division of Urology Children’s Memorial Hospital – Chicago Professor of Urology Northwestern

MODULE 3 1/113 Module 3: Treatment of BPH J. Curtis Nickel, MD, FRCSC Program Chair, Chief Editor Professor of Urology, Department of Urology Queens University

Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

CURRICULUM VITAE - medicine.ju.edu.jomedicine.ju.edu.jo/Lists/FacultyAcademicStaff... · CURRICULUM VITAE Mohammad Majed Abufaraj Assistant Professor of Urology Division of Urology

UROLOGY PME Urology...D. Robert Siemens, MD, FRCSC Professor and Chair Dr. Siemens is currently Professor and Chair of the Department of Urology and is cross-appointed to the Departments

Dr Zakir Hussain Rajpar Assistant Professor Of Urology Liaquat University Of Medical And Health Sciences