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