TEALE FENNING

EMAK · Century Club Joined: 26 Nov 2006 Posts: 570

Question 1

Below is a list of options for the management of urinary incontinence.
Following it are three clinical scenarios. For each scenario, choose the most appropriate treatment option. Each option in the list can be chosen once, more than once or not at all.

A. TVT
B. TOT
C. Colposuspension
D. Anterior colporrhaphy
E. Artifical urinary sphincter
F. Intraurethral NASHA/DX copolymer injection
G. Sacral neuromodulation
H. Urinary diversion
I. Botulinum A Toxin
J. Augmentation cystoplasty
K. Rectus fascia pubovaginal sling
L. Needle suspension

(i) An 83-year-old woman in poor medical health with
urodynamic stress incontinence and normal voiding parameters

(ii) A 44-year-old woman with urge incontinence and severe detrusor overactivity on urodynamics unresponsive to conservative therapy and anticholinergic medications

(iii) A 56-year-old woman with urodynamic stress incontinence and no previous surgery; her family is complete and there is no prolapse on examination
Wink

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

hi emak,

really nice ones. they should spark some nice discussions. let's see how people respond.

Laughing

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

wolverine · Century Club Joined: 16 Jan 2007 Posts: 393

Hi EMAK! Good ones. Hi Raj! Why are you not giving your answers??
I think for q1 and q3 is TVT (could be TOT but there is still not strong enough evidence for their success and I think NICE guidline's 1st choice is still classic TVT)
For q2 I think that sacral neuromodulation has shown better results than botox. I can't find any other suitable option

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

hi wolverine,

i wasn't giving answers as i wanted the exam going people to have a go first. any way my answers are..........

1. F - urethral bulking / macroplastique --- patient is old and debilitated, hence i'll prefer an outpatients macroplastique instead of the more invasive TVT.

2. I -- botox . i would have actually preferred cystistat i.e. hyaluronidase but that option is not available. from what i remember having read botox though new has better results than neuromodulation.

3. A -- TVT, has been around longer, results compared in RCT and more tape erosions with TOT.

Very Happy

_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

drhatta · Joined: 20 Feb 2007 Posts: 32 Location: Malaysia

My answers would be
1. F
2. I
true Raj..
3. TVT or TOT Confused

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Tension-free vaginal tape versus transobturator tape
Risk of bladder injury and voiding difficulties is significantly higher with retropubic compared with transobturator slings, and that the risk of urethral injury is significantly lower with retropubic slings. When comparing TVT alone with the TOT procedure, the same
pattern is seen:
bladder injury: RR 6.14 (95% CI 3.69 to 10.22)
urethral injury: RR 0.23 (95% CI 0.08 to 0.62)
voiding difficulties: RR 2.83 (95% CI 2.05 to 3.89).
The findings should be viewed with caution because most of the data used in the pooling are derived from indirect comparisons of the interventions.

Ref: Nice Guideline

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

NICE guideline has made a recommendation that SNS be used in the treatment of UI due to DO in women who have not responded to conservative treatments and we expect it to be a lowvolume intervention.

SNS has high initial treatment costs and requires a battery replacement after approximately 7 years. However, as this cost–consequence analysis shows, the alternative treatment options for this group of women with refractory incontinence are all expensive, and the incremental costs of SNS when compared with the alternatives are much less (and possibly even negative) than when looking at the costs of SNS in isolation. A cost–consequence analysis does not demonstrate cost effectiveness and it is difficult to compare effectiveness in a quantitative way. However not only does major surgery such as augmentation cystoplasty or urinary diversion carry a high cost over time but the morbidity is also high and only around 50% of patients are satisfied with the outcome.

Although botulinum toxin A injection appears to offer promising results the current evidence is limited; it is assumed that repeated injections will be required. The incremental costs over time are therefore likely to be very high. We believe that this cost–consequence analysis provides an economic justification for the recommendation made.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Sacral nerve stimulation

Cost (10 year)

£8,437 + replacement battery + surgical revisions

Up to two-thirds of patients achieve continence or substantial improvement in symptoms after SNS; the available data show that beneficial effects appear to persist for up to 3–5 years after implantation. Around one-third of patients may require re-operation, most often owing to pain at the implant site, infection, or the need for adjustment and modification of the lead system. Permanent removal of the electrodes may be required in one in ten patients. Developments in the devices and leads have resulted in reduced rates of complications since introduction of the technique.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Botulinum toxin A
Cost

£9,296 + self-catheterisation costs
Data on the use of botulinum toxin A in the management of idiopathic detrusor overactivity are limited. The available data show cure or improvement in about half of patients, with duration of benefit between 3 and 12 months.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

EMAK · Century Club Joined: 26 Nov 2006 Posts: 570

(i) F
In view of the fact that this is an elderly patient in poor health,
intraurethral bulking agents offer the best hope of improvement
associated with the lowest morbidity. In addition, NASHA/DX
can be injected under local anaesthesia in an outpatient setting.
(ii) I
Although long-term data are awaited, botulinum A toxin has
been associated with good success rates and is less invasive
than both neuromodulation and augmentation cystoplasty.
(iii) A
Current evidence suggests that TVT is the most appropriate
procedure with the most complete outcome data, with the
exception of colposuspension. TVT is less invasive than colposuspension.
TOT could also be considered.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 788

Emak,
Thank you for posting a really good set of questions.

Any particular source?

cpeed

EMAK · Century Club Joined: 26 Nov 2006 Posts: 570

Thanks Cpeed.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

hi all,

try these........

1. 26 yrs old, history of intermittant visual changes with optic neuritis, pins and needles, continuous urinary leak, fluctuating peripheral muscle weakness. what's the best option for her?

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

2. alien from andromeda, survivor of spaceship crash, settled on and adapted to earth for the last 100yrs, develops continuous urinary leak??? Rolling Eyes

_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

3. a fit 63 yr old, previous stamey's repair with urodynamic incontinence now?
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

4. 45 yrs old, symptoms of urgency, frequency, abdominal hysterectomy for fibroids 2 yrs ago, large cyctocoele affecting sex life.?
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

wolverine · Century Club Joined: 16 Jan 2007 Posts: 393

wolverine · Century Club Joined: 16 Jan 2007 Posts: 393

EMAK · Century Club Joined: 26 Nov 2006 Posts: 570