# Presentation: 059485

## Stress Urinary Incontinence

- MONARC vs. Paravaginal wall Repair:  A system and surgeon perspective
- Dr. Richard McClain, MD, FACOG
- Chief of OB/GYN, Chickasaw Nation Health System

## The Problem

- Symptom- the complaint of involuntary leakage of urine during effort, exertion, coughing or sneezing
- Sign-The observation of leakage from the urethra synchronous with cough or exertion or spontaneously

## DEFINITION OF URINARY INCONTINENCE

***The objective loss of urine that presents a social***
*** ******or hygienic problem to the individual. Incontinence ***
***is not a normal part of aging nor is it a disease.***
**	**

## IN THE U.S.

- Approximately 11 million women suffer from incontinence4
- Urinary incontinence occurs in1:
**50% of otherwise healthy women at some stage in their lives**
**Roughly 20% of women between the age of 15 and 64**
**About one-half of the elderly have episodes of incontinence**

## STRESS URINARY INCONTINENCE  (SUI)

**	****CAUSES**
- Pregnancy and childbirth
- Pelvic injury or surgery
- Estrogen deficiency
- Weak pelvic floor muscles
- Back injury or surgery

***Involuntary loss of urine during exertion****** ***
*(lifting, jogging, sneezing, laughing)*

## (SUI Continued)

**TWO MAIN CATEGORIES**
**HYPERMOBILITY**
- 	Loss of urine related to** **_movement of the bladder neck and urethra_ triggered by abdominal straining (lifting, jogging)
**INTRINSIC SPHINCTER DEFICIENCY (ISD)** Leakage of urine with minimal exertion related to an _intrinsic weakening of the bladder outlet closure mechanism_

**Most Common in**
** ****Women**

## URGE INCONTINENCE

**CAUSES**
- Urinary tract or vaginal infections
- Bladder tumor/stones
- Neurological causes (MS, Parkinson’s, spinal cord injury)

***Sudden, uncontrollable urge to void, resulting in leakage of urine***

## CLINICAL EVALUATION

**by a Thorough evaluation physician:**
**History:** symptoms, bowel habits, medical history
**Physical Examination****:** neurologic examination, abdominal exam, pelvic examination
**Urodynamics****:** a series of diagnostic tests used to measure how the bladder fills, stores and expels urine

## My Approach

- Subjective- affects lifestyle/activity, Sandvik Severity Scale and Incontinence Quality of Life Questionaire (included)
- Objective- leaking with cough or Valsalva in the clinic
- Conservative therapy- one month trial of Kegel’s exercises and Ditropan
- Urodynamics for special cases

## SURGICAL TREATMENTS

*The goal of a surgical procedure to correct ****SUI**** is to:*
- Reposition the bladder neck to minimize hypermobility of the urethra during stress
- Improve the coaptation of the urethra so it closes more effectively

## HYPERMOBILITY:

**Needle suspensions (Urethropexies)**
- Stamey, Raz, Gittes
**Retropubic suspensions (Urethropexies)**
- Burch, MMK
**Sling procedures**
- Suprapubic and Transvaginal

## ParaVaginal Wall Repair

-   -Retro pubic repair that seeks to recreate normal anatomy
- 	-Modified to include a mid-urethral stitch in some patients
- 	-Requires transverse incision
- 	-Equivalent success to Burch Colposuspension
- 	-Gold Standard for SUI surgery

## Slide 13

## Slide 14

## Slide 15

## SLINGS vs. OTHER SURGICAL INTERVENTIONS

**Addresses hypermobility and ISD**
**More durable than bulking**9
**Least invasive surgical procedure - same day surgery is common**
**AUA Guidelines indicate slings most effective surgical procedure for long-term treatment of female SUI**

## The Monarc® Subfascial Hammock: a Transobturator Approach

- Helical needles centered over shaft designed to avoid retropubic space perforation
- Outside-to-in design optimizes safety
- Loosely knitted polypropylene mesh for fibroblast in-growth and integration
- Unique, patented tensioning suture prevents distortion during sling placement to minimize potential for overcorrection
- 3 needle choices for physician preference

## Reasons to Consider Monarc®

- Reproduces natural suspension mechanism
- Minimizes risk for overcorrection / dysuria
- Safe passage
- Needles move immediately away from obturator canal
- Anatomically designed needles minimize risk for vascular, bowel, bladder injury
- Cystoscopy optional
- Designed to be easy to learn and to teach
- Salvage procedure after failed retropubic surgery

## Inferior Epigastric Vessels

- Obturator vessels

- Ext. Iliac
- Vessels

- Courtesy of Dr. Walters, Cleveland, USA

- 3-4 cm medial from the obturator canal

- Monarc mesh lies below the endopelvic fascia

## Monarc® Mesh Position

**SPARCTM/TVTTM**

**MonarcTM**

- Reiffenstuhl ,Platzer & Knapstein

## Needle Path

- Use thumb of hand in vaginal incision to perforate
- Rotate the needle after obturator membrane perforation to exit the vaginal incision

## Why Utilize the Monarc (Outside-In) Transobturator Approach?

- Reproduces natural suspension mechanism
- Minimizes risk for overcorrection / dysuria
- Safe passage
- Needles move immediately away from obturator canal
- Anatomically designed needles with centered helix minimize risk for vascular, bowel, bladder injury
- High efficacy with relatively little post-operative pain
- _Backed by clinical data!_

## System Issues

- Efficacy of current procedures
- Patient Benefit of new procedure
- Safety of new procedures
- Cost of the procedure/kit
- Credentialing for new procedures

## System Issues

- Efficacy of current procedure- were doing Burch with 50% effectiveness, had been doing TVT and SPARC
- Higher than expected bladder perforation rate
- Post operative hospitalization for Retro-
-    pubic procedures was 76 hours (3rd day)

## MONARC-     Pre op       post op                                                 pre op      post op

- Sandvik Scale-8/8            0/8        Incontinence quality of life- 35/92        92/92
-                       *6/8              6/8                                                      30/92        34/92
-                         3/8              0/8                                                      60/92        92/92
- 	    8/8	         0/8			                  35/92         92/92
-                      6/8                 0/8                                                      54/92        92/92
- 	          8/8              1/8                                                      28/92         71/92
-                         3/8              1/8                                                      58/92         88/92
- 		8/8              0/8                                                      35/92         92/92
- 		4/8              0/8                                                      43/92         90/92
- 		8/8              0/8                                                      23/92         92/92
- 	            6/8	        0/8                                                     35/92         92/92
-  Complications- one pt with hesitancy/slow flow, one patient with  continued
-  self cath and subsequent release,  one repeat procedure for recurrence
-  due to pneumonia
- PVW repair      Pre op      post op                                                  pre op    post op
- Sandvik Scale-  8/8          0/8          Incontinence quality of life- 28/92      91/92
-                           8/8          0/8                                                        25/92      92/92
-                         *6/8          6/8                                                        66/92      87/92
- 		   8/8          1/8                                                       44/92      92/92
- 		  8/8           0/8                                                       28/92      91/92
- 		 3/8            0/8                                                       59/92      92/92
- Complications- return to OR for bowel complications

## System Issues

- Have health system policy that addresses cost, safety and workload impact issues
- Credentialed based on evidence for didactic and practical training with appropriate review of outcomes
- Did cost analysis and subsequent bulk buy of kits based on need

## Outcome for our Facility

- Monarc/SPARC- 70 procedures done
- Average operative time- 45 minutes
- Post-operative stay- 34 hours
- 10% done as an outpatient
- Decreased bed usage translated to fewer transfers
- Patient recovery time markedly improved

## Outcome for our Facility (cont)

- Reproducible between providers
- Significant improvement in patient satisfaction
- Enhanced reputation/standing in the eyes of the patients and community

## Pearls from Experience

- Make sure patients understand that some will have to be tightened, loosened or replaced
- Not all incontinence is treated with surgery
- No one can guarantee they’ll never leak again
- Cystoscope everyone!!