General Urology Urological Oncology Kidney Stones Female Urology Minimally Invasive Surgery

Urinary incontinence (UI) or the involuntary leakage of urine is a distressing and serious health problem.  Its psychosocial and economic burden leads to significant quality of life issues. UI is more prevalent than hypertension, depression and diabetes, yet underreported with fewer than half of all patients willing to report their symptoms to their physicians. The urological surgeons at The University of Kansas Hospital are skilled at diagnosis and treatment of these conditions. Female gender alone is a predisposing factor for UI, most affected by childbearing and number of pregnancies.

The three most common types of UI are stress urinary incontinence (SUI), urge urinary incontinence (UUI), or a combination of both, mixed urinary incontinence (MUI). ).  The International Continence Society provides the following definitions:

• Stress Urinary Incontinence (SUI) is the involuntary leakage on effort or exertion, or on sneezing or coughing.
• Urge Urinary Incontinence (UUI) refers to involuntary leakage accompanied by or immediately preceded by urgency.
• Mixed Urinary Incontinence (MUI) is the involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing.

Stress Urinary Incontinence - results from bladder neck/ urethral hypermobility and/ or neuromuscular defects, i.e. intrinsic sphincter deficiency.  This occurs when the intra-abdominal pressure exceeds urethral resistance.

Among women, these changes occur due to weak collagen, advanced age, pregnancy, obesity, advanced pelvic prolapse and chronic obstructive airway disease. Our fellowship-trained physicians can help you navigate the treatment options best for you. Dr. Tomas Griebling and Dr. Priya Padmanabhan are the only fellowship trained female and voiding dysfunction urologists in Kansas and Missouri, offering the latest techniques in diagnosis and management of difficult female urologic problems. . Our facilities provide “state of the art” videourodynamic equipment to provide specific information about the most complicated conditions in the bladder and urethra. Dr. Griebling and Dr. Padmanabhan have specialized training in interpreting the results of such testing to ensure proper management of their condition. The treatment options for stress urinary incontinence include:

1. Conservative - voiding frequency, fluid modification, pelvic floor rehabilitation therapy
2. Non-surgical - intra-urethral plug, pessary
3. Surgical
• Minimally Invasive
  Bulking injections are an endoscopic option for injection of synthetic material (Coaptite® or Macroplastique®) in the tissues at the bladder neck. This helps partially close the opening of the urethra and improve continence. This is performed through a cystoscope  as a same day procedure.
  
  Bulking injection
  
  The minimally invasive mid-urethral slings were approved by the FDA in 2006 and have been a valuable addition to or treatment options since Dr. Padmanabhan’s arrival in September 2010. The appeal of this technology is the single-incision, shorter hospital stay, and reduced postoperative pain. Intermediate-term data reveals the outcomes similar to the previously accepted mid-urethral sling options.
  
  
• Invasive
  The gold standard for stress urinary incontinence introduced in the 1940s and popularized in the 1970s is the pubovaginal sling (pvs), which is placed at the bladder neck. This can utilize autologous (self tissue), cadaveric tissue or xenograft (animal based tissue) for the graft material. This is associated with high success rates and high patient satisfaction. Our female urologists have the largest experience with the placement of pvs in this region of the country.

Urge Urinary Incontinence - is considered classically due to an overactive bladder muscle (OAB) or an incompetent urethral sphincter.

The underlying pathophysiology of OAB can relate to alterations in any of the reflex cycles in normal urination or structural changes in the smooth muscle, nerves or lining of the bladder. Treatment of OAB is based on diagnosis after excluding other pathologies, i.e. urinary tract infection, bladder stone, diabetes.  Dr. Griebling and Dr. Padmanabhan provide the following options:

1. Conservative - lifestyle modification, bladder training, drug therapy (anticholinergic)
2. Minimally invasive - Botulinum toxin (Botox®) . These are intramuscular bladder injections performed through a cystoscope in a same day setting. Dr. Padmanabhan has had success with Botox® for patients crippled with incontinence that was unresponsive to other treatments
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   Botox®
3. Invasive - sacral nerve stimulation (InterStim®). The principles of treatment are to increase voided urinary volumes (thereby reducing urinary frequency and nighttime urination), decrease urgency and reduce UUI episodes. Dr. Griebling is nationally recognized for his contributions in geriatric incontinence and has the largest experience with sacral neuromodulation in the area.

Mixed Urinary Incontinence (MUI) is often treated as part of the treatment of SUI and UUI. This approach should be individualized, depending on the severity of each component.

PELVIC ORGAN PROLAPSE

Pelvic organ prolapse (POP) is due to thinning or stretching of the collagen fibers in the connective tissue holding up the uterus, bladder, rectum and/or perineum. POP affects over 30% of all women and 50% of women who have delivered a child.  It is often described as “a woman’s hernia” and may worsen with aging, requiring repair. This often presents as a bulge in the vagina, which may disappear while lying down. Other presentations may be difficulty with emptying of the bladder or bowels, pain or pressure in the vagina, recurrent urinary tract infections, or limitations with sexual intercourse.

Dr. Priya Padmanabhan is the only fellowship-trained urologist in Kansas and Missouri with extensive knowledge in the diagnosis and treatment of POP. Diagnosis generally involves assessment with videourodynamics, a “state of the art “ test providing specific information about conditions of the bladder and urethra. This is especially beneficial in the management of urinary incontinence, which often goes hand-in-hand with prolapse. At KU, treatment options available for prolapse treatment include:

1. Conservative - pessary
2. Surgical
   • Vaginal - This includes surgery through the vagina to repair one more of the affected components of the prolapse (anterior or cystocele, apical and posterior or rectocele).
   • Abdominal sacrocolpopexy – This was historically the gold standard for repair of apical prolapse and is now reserved for complex cases which have failed multiple prior vaginal and/ or robotic repairs.
   • Robotic - this a state-of-the-art minimally invasive surgery performed through 3 to 4 1-2 cm incisions using the da Vinci System®. This ideally provides greater precision and control . Patients experience less pain and blood loss, shorter hospital stay and have shorter recovery times. This continues to maintain excellent clinical outcomes.

MESH EROSION OR EXTRUSION

In 2008, the FDA issued a warning against nine mesh manufacturers as stated below:
http://www.fda.gov/medicaldevices/safety/alertsandnotices/publichealthnotifications/ucm061976.htm
which was subsequently updated July 2011:
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm

This has led to much discussion among patients, physicians, lawyers and nationally among the American Urological Association (AUA) and the American Urogynecology Society  (AUGS). The general opinion of these two organizations is as follows:
http://www.auanet.org/content/aua-policies/position-statements.cfm
http://www.augsmeeting.org/p/cm/ld/fid=202

Patients are generally extremely distressed and require a comprehensive evalution with physical exam, cystoscopy and urodynamics to plan treatment. We are fortunate to have extensive experience in the management of these complications. Dr. Padmanabhan has presented nationally and recently published on the largest database to date of foreign body complications from pelvic surgery, The Journal of urology, March 2012, Epub.