Dr. Castro-Diaz talks about the Turner-Warwick and how urethral hypermobility and intrinsic sphincter deficiency may be on a spectrum.
How is the urethra evaluated? There is no good test to evaluate urethral function. The following can be done for evaluation: history and physical exam, Bonney-Marshall/TVT Test, Q-tip test, bladder neck morphology, abdominal leak point pressure, urethral pressure profile, cystoscopy, ultrasound, MRI.
He then goes to discuss how evaluation for ISD is more difficult in neurogenic bladder patients. With sphincter deficiency a bladder augment may not be enough and the patient may need sling or sphincter. With the availability of new tools like ultrasound and MRI, placement of slings can be evaluated (ie near the bladder neck or urethra).
What happens after a sling fails? There are many other options available after the failure of the sling. He does mention that a fascial sling is preferred by urologists and he demonstrates a technique he uses; a mini fascial sling harvested from rectus fascia.
Remeex is an adjustable sling that can be used for ISD. Over 20 studies over 5 years regarding Reemex device have been done that show longterm outcome is good with low rate of complications.
He mentions that urethral bulking agents can improve continence but may not necessarily leave a patient completely dry. This, however, can be a viable option for patients who cannot undergo surgery.
The artificial urinary sphincter via a vaginal approach is not really performed anymore. In France, sphincters are implanted via an open procedure. Now laparoscopic and robotic options are available. The artificial sphincter outcomes are generally good achieving a 90% continence rate. The complication rate may be a little higher than other options. HE presents DR. PEyronnets data
The outcome is good. Allows 90% to obtain continence. Does have complications.
Dr. Castro-Diaz concludes his talk with the following summary of lessons learned about ISD.
- The evaluation of ISD is not an easy task
- all incontinent women must have some sphincter deficiency
- many women with OSD might respond to the standard procedure
- The fascial sling is the most commonly used procedure
- adjustable sling is an option to be considered
- bulking agent do not cure but improve continence and QoL
- AUS provide high success but with a high complication rate