Introduction

The true incidence of voiding dysfunction and iatrogenic obstruction after anti-incontinence surgery is unknown and likely underestimated because of underdiagnosis, misdiagnosis, variations in definition, and underreporting. Reported rates of obstruction vary depending on the type of anti-incontinence surgery performed. Urinary obstruction requiring intervention after any anti-incontinence surgery occurs in at least 1% to 2% of patients even in the hands of the most experienced surgeon.

Voiding dysfunction after surgery for stress urinary incontinence (SUI) can be related to various degrees of obvious outlet obstruction, de novo development of detrusor overactivity, or a significant worsening of pre-existing detrusor overactivity. Historically, textbooks have also discussed the potential for impaired contractility to be a cause in such situations. When patients present with various degrees of voiding dysfunction or symptomatic overactive bladder symptoms, the surgeon must go to great lengths to construct a management plan to address these very distressing symptoms.

Patients with iatrogenic obstruction or voiding dysfunction after surgery for SUI can present with many symptoms. The most obvious signs and symptoms include complete or partial urinary retention, inability to void continuously, and the presence of a slow stream with a prolonged voiding time with or without intermittency. Also, many women with milder forms of outlet obstruction complain of having to lean back or even stand up to void. Some women do not have obstructive voiding symptoms and present mainly with the de novo development of irritative symptoms of frequency, urgency, and urge incontinence. Women may also present with a combination of voiding and storage symptoms. The clinical challenge is to determine whether these symptoms can be directly correlated to outlet obstruction secondary to either sling placement being too tight or overzealous tightening of suspension sutures.

Transient voiding dysfunction and retention can occur frequently and to a certain degree are expected to occur after certain types of anti-incontinence surgery. It is common for a patient to have retention for days to weeks after a biologic pubovaginal sling or certain suspension procedures. Patients with synthetic sling procedures done in isolation should void immediately postoperatively or shortly thereafter in most cases. Table 9-1 presents reported rates of obstruction after various sling and suspension procedures. When a surgical intervention for iatrogenic voiding dysfunction is believed to be necessary, controversy exists regarding the timing and techniques for these procedures. Preoperative cystourethroscopy should always be performed because the surgeon needs to ensure there is no sling material or sutures within the urethra or the bladder. Also, depending on the clinical situation, urodynamics studies may be helpful in documenting iatrogenic outlet obstruction as the cause for the patient’s symptoms.

Table 9–1 Reported rates of obstruction from various sling procedures

TVT, Gynecare TVT Retropubic System (Ethicon Women’s Health and Urology, Somerville, NJ); TVT-O, Gynecare TVT Obturator System Tension-Free Support for Incontinence (Ethicon Women’s Health and Urology); TVT-Secur, Gynecare TVT Secur System (Ethicon Women’s Health and Urology); SPARC, SPARC Self-Fixating Sling System (American Medical Systems, Minnetonka, MN).

CIC, Clean intermittent catheterization; NA, not available.

From Nitti VW, ed. Vaginal Surgery for the Urologist. Philadelphia: Saunders; 2012.

Traditionally, evaluation has been delayed for at least 3 months after surgery; this was based on literature following pubovaginal slings, colposuspension, or needle suspension where recurrent SUI after intervention was minimized by waiting at least 90 days. This waiting period that has been advocated for these traditional procedures has largely been abandoned for retropubic, transobturator, and single-incision synthetic midurethral sling procedures. Because of immobility of mesh and tremendous ingrowth of fibroblastic tissue by 2 weeks postoperatively, patients with retention or severe symptoms are unlikely to improve much beyond this time period. After retropubic and transobturator tape procedures, milder forms of temporary voiding dysfunction have been reported to resolve in 25% to 66% of patients in 1 to 2 weeks and 66% to 100% of patients by 6 weeks. Based on these data and our experience, waiting beyond 6 weeks for work-up and intervention seems unwarranted. Some authors would also argue that because 66% of patients should have symptoms resolve within 2 weeks, work-up and possible intervention are warranted at the 2-week mark or earlier after discussion with the patient about symptoms, level of bother, and willingness to risk possible intervention. In our practice, if a patient is unable to void spontaneously (i.e., urinary retention) within 1 week after a retropubic or transobturator tape procedure, we consider and discuss loosening the sling at that time, provided that a simultaneous pelvic organ prolapse repair was not done.

The work-up should include a focused history, physical examination, cystourethroscopy, and urodynamics testing in selected cases. Key points in the history are the patient’s preoperative voiding status and the temporal relationship of new symptoms to the surgical procedure for SUI. Physical examination should focus on the angulation of the urethra. The urethra should be evaluated to determine if it appears to be hypersuspended and whether the urethral meatus appears to be pulled toward the pubic bone because a more vertical angle of the urethra suggests obstruction. However, most patients after synthetic midurethral sling procedures do not appear overcorrected. Patients should be examined for prolapse, urethral hypermobility, and recurrent SUI. As previously mentioned, cystourethroscopy should be performed to rule out any sling material in the urethra or bladder and to evaluate for any scarring, narrowing, occlusion, kinking, or deviation. It is also helpful to rule out any unsuspected pathology, such as a urethral diverticulum or bladder lesion.

Urodynamics testing can be performed if there is doubt regarding the diagnosis based on history, physical examination, and noninvasive testing (uroflow or post-void residual). There are no universally accepted urodynamics criteria for bladder outlet obstruction. Classic high pressure–low flow voiding dynamics confirm the diagnosis but are not always present even with significant obstruction owing to the differing voiding dynamics in women compared with men. For patients with complete retention shortly after surgery, urodynamics is of minimal diagnostic benefit. In a patient with retention, urodynamics can be used to identify detrusor instability and impaired compliance and confirm the diagnosis of obstruction. For a patient with predominately de novo storage symptoms with normal emptying, urodynamics can help identify or rule out obstruction. In these situations, many clinicians believe videourodynamics is preferable to standard urodynamics because the site of obstruction can be identified by fluoroscopy regardless of pressure and flow dynamics.

Technique for Synthetic Sling Loosening in the Acute Setting (7 to 14 Days)

This technique is suitable to be performed in the office in a cooperative patient. However, it can be done in the operating room with very light intravenous sedation and local anesthesia in patients who are extremely anxious or intolerant of pain. It is best to perform this procedure before 14 days because after this time tissue ingrowth may prevent loosening, in which case it would most likely be preferable to cut the sling.

Case 2: Takedown of Retropubic Synthetic Sling at 4 Months Postoperatively

A 65-year-old woman presents approximately 4 months after vaginal hysterectomy with vaginal repairs of a cystocele and rectocele and a retropubic synthetic midurethral sling. She is still performing intermittent self-catheterization numerous times a day for significant voiding dysfunction. She voids 50 to 150 mL and persistently has residual volumes of 200 to 400 mL. The synthetic midurethral sling procedure was performed for suspected occult or potential SUI. Otherwise, she has no complications from the surgery and has had a very good result in regard to correction of prolapse. She denies any significant irritative symptoms in the form of frequency, urgency, or urge incontinence. The patient is becoming very frustrated with having to perform catheterization and desires resolution to the problem if available. Cystourethroscopy reveals no evidence of any injury to the urethra or bladder secondary from the previous surgery. Urodynamics studies note a stable detrusor to the volume of 450 mL with no evidence of any recurrent SUI. She is able to void only 120 mL during an attempted pressure flow study, but this is associated with significant abdominal straining and a detrusor contraction of 35 cm H₂O. After a detailed discussion of the potential surgical intervention, the patient agrees to a transvaginal excision of the suburethral portion of the synthetic mesh with the hope of having her voiding efficiency return to normal. She undergoes excision of the synthetic sling and has an immediate resumption of normal voiding with no evidence of recurrent SUI.

Discussion of Case

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

Bladder Augmentation Mixed and Recurrent Incontinence, Incontinence in Patients with Pelvic Organ Prolapse, and How Best to Avoid and Manage Complications: Case Discussions Single-Incision Synthetic Midurethral Slings Transobturator Synthetic Midurethral Slings Surgical Anatomy of the Anterior Vaginal Wall, Retropubic Space, and Inner Groin Sacral Neuromodulation

Stay updated, free articles. Join our Telegram channel

Join