Sling Operasyonlari TOT,TVT ve Endikasyonlari

1. Sling Operasyonlari (TOT,TVT ) ve Endikasyonlari Prof.Dr.S.Cansun DEMIR �ukurova �niversitesi Tip Fak�ltesi Kadin Hastaliklari ve Dogum AD

2. Stress Inkontinans ABD�de her yil 100.000 kadina �riner inkontinans operasyonu (Boyles 2003, 2004) 85,000 yatarak 15,900 outpatient procedures �I cerrahi girisim sayisi ikiye katlandi (1979 - 1997 (her 3 operasyonun biri TVT ve benzeri girisim, Rosenblatt 2004)

5. Midurethral sentetik slingler Midurethra teori ( Integral teori ) Petros and Ulmsten SUI nedeni: Pubourethral ligamanlarda zararlanma Suburethral vaginal hamakta zayiflama Pubococcygeus kasin zayif fonksiyonu

6. TVT �operasyon teknigi The first operation that was introduced was TVT. Operations can be done under local or epidural anesthesia The para�rethral tissues were dissected through small, suburethral vaginal incision. A special prolene tape covered by a plastic sheath was introduced using a two component needle instrument. The tape was applied around the mid-�rethra. Bladder was checked by cystoscopy for any inadvertent damage. Bladder neck was elevated under the vision of cystoscopy. The vaginal and abdominal incisions were sutured primarily after cutting the abdominal ends of the tape in the subcutaneous tissue without any fixation.The first operation that was introduced was TVT. Operations can be done under local or epidural anesthesia The para�rethral tissues were dissected through small, suburethral vaginal incision. A special prolene tape covered by a plastic sheath was introduced using a two component needle instrument. The tape was applied around the mid-�rethra. Bladder was checked by cystoscopy for any inadvertent damage. Bladder neck was elevated under the vision of cystoscopy. The vaginal and abdominal incisions were sutured primarily after cutting the abdominal ends of the tape in the subcutaneous tissue without any fixation.

7. TVT- etkinlik

8. TVT- SUBGRUPLAR

9. TVT vs Burch

10. Karsilastirmali �alismalar :TVT vs Slingler

11. Eleven years prospective follow-up of the tension-freevaginal tape procedure for treatment of stress urinaryincontinenceC. G. Nilsson & K. Palva & M. Rezapour & C. FalconerInt Urogynecol J Pelvic Floor Dysfunct. 2008 Aug;19(8):1043-7.  Baslangi�taki 90 olgunun % 77si, TVT operasyonundan 11.5 yil sonra degerlendirildi� . In a Nordic three-center prospective observational cohort study, 90 women with primary stress incontinence had a TVT operation performed in local anesthesia. Assessment included a 24-h pad test, a stress test, physical examination, and a visual analog scale for assessing the degree of bother. Patient�s global impression of cure was obtained, and condition specific quality of life questionnaires were used. In a Nordic three-center prospective observational cohort study, 90 women with primary stress incontinence had a TVT operation performed in local anesthesia. Assessment included a 24-h pad test, a stress test, physical examination, and a visual analog scale for assessing the degree of bother. Patient�s global impression of cure was obtained, and condition specific quality of life questionnaires were used.

12. Eleven years prospective follow-up of the tension-freevaginal tape procedure for treatment of stress urinaryincontinenceC. G. Nilsson & K. Palva & M. Rezapour & C. FalconerInt Urogynecol J Pelvic Floor Dysfunct. 2008 Aug;19(8):1043-7.  90% objective cure.. 77 % subjective cure... 20% iyilesme �. Yalnizca % 3 olgu operasyonu basarisiz olarak degerlendirdi.. Ge� komplikasyon yok. �. Erozyon yok �. Ninety percent of the women had both a negative stress test and a negative pad test being objectively cured. Subjective cure by patients global impression was found in 77 %, 20% being improved and only 3 % regarded the operation as a failure. No late-onset adverse effects of the operation were found, and no case of tape erosion was seen. Ninety percent of the women had both a negative stress test and a negative pad test being objectively cured. Subjective cure by patients global impression was found in 77 %, 20% being improved and only 3 % regarded the operation as a failure. No late-onset adverse effects of the operation were found, and no case of tape erosion was seen.

13. Eleven years prospective follow-up of the tension-freevaginal tape procedure for treatment of stress urinaryincontinenceC. G. Nilsson & K. Palva & M. Rezapour & C. FalconerInt Urogynecol J Pelvic Floor Dysfunct. 2008 Aug;19(8):1043-7.  TVT operasyonu 10 yilin �zerinde s�reyle g�venli ve etkindir.

14. Transobturator tape TOT De Lorme 2001.. (outside-in ) De Leval 2003 (inside-out) 200.000�den fazla operasyon�.. Sistoskopi sart degil obez hastalar� abdominal / retropubik operasyon ge�irmis olanlar. Vaginal operasyonlarla uyumlu�. Basit ve etkin

15. TOT sling angle is much less acute than traditional sling, it is felt that this angle is more natural and may reduce post-op voiding dysfunction.The TOT sling (red) is shown in this MRI to mimic the natural position of the pubourethral ligament (green) which is the ligament known to be responsible for maintaining continence. TOT sling angle is much less acute than traditional sling, it is felt that this angle is more natural and may reduce post-op voiding dysfunction.The TOT sling (red) is shown in this MRI to mimic the natural position of the pubourethral ligament (green) which is the ligament known to be responsible for maintaining continence.

16. The needle to place the TOT sling is passed through the groin incision, the obturator membrane and around the descending ischiopubic ramus (the area marked in green in the above diagram The obturator vessels and nerve coming through the canal (in pink above) are far away from the surgical field, thus making injury very unlikely. The needle to place the TOT sling is passed through the groin incision, the obturator membrane and around the descending ischiopubic ramus (the area marked in green in the above diagram The obturator vessels and nerve coming through the canal (in pink above) are far away from the surgical field, thus making injury very unlikely.

17. A small incision is made vaginally as well and the needle is guided throughout its course with a finger placed in the vaginal incision, thus protecting the urethra and making it safer than just a blind needle passage. The mesh tape (the same mesh tape that is used for SPARC, TVT sling etc) is then attached to the needle and brought back through the incision A small incision is made vaginally as well and the needle is guided throughout its course with a finger placed in the vaginal incision, thus protecting the urethra and making it safer than just a blind needle passage. The mesh tape (the same mesh tape that is used for SPARC, TVT sling etc) is then attached to the needle and brought back through the incision

21. TOT Inside -out

22. OUT vs IN

23. OUT vs IN

24. OUT vs IN

25. OUT vs IN Her iki trans-obturator yol esit olarak etkin ve g�venlidir�

31. TVT vs TOT Transobturator yaklasim daha az bir komplikasyon oranina sahiptir; ancak objektif ya da subjektif verilere dayanarak, bir y�ntemin digerine �st�nl�g�n� bug�n i�in �ne s�rmek m�mk�n degildir..

33. SONU�LAR - 1 Stres inkontinasta operatif se�im, urethral hipermobilite ve intrensek sfinkter yetmezliginin ortaya konmasiyla iliskilidir. Her iki etyoloji degisik oranlarda birlikte bulunabileceginden uygulanacak cerrahi y�ntemin iyi bir klinik degerlendirme sonrasi verilmesi gerekmektedir.

34. SONU�LAR - 2 Midurethral polypropilen slingleri her t�r inkontinans olgusunda uygulama egilimi yayginlasmaktadir. Y�ksek basari oranlari ve vaginal operasyonlarla es zamanlilik degerini arttirmaktadir. Diger t�m anti-inkontinans operasyonlari- yerini b�y�k oranda midurethral sentetik slinglere birakmistir.

35. SONU�LAR- 3 TOT uygulamalari giderek artmakta ve � basit, direkt ve hizli � bir prosed�r olarak tanimlanmaktadir. Midurethral slinglerin inkontinans cerrahisindeki ger�ek yeri kontroll� , randomize �alismalarin ve uzun vadedeki sonu�larin ortaya �ikmasindan sonra berraklasacaga benzemektedir�