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ORIGINAL RESEARCH |
From the University of Southern California, Los Angeles, California and the Departments of Gynecology and Obstetrics and Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
Address reprint requests to: William H. Kobak, MD, LAC/USC Women’s and Children’s Hospital Department of Obstetrics and Gynecology, 1240 North Mission Road, Room L1022, Los Angeles, CA 90033, E-mail: kobak{at}hsc.usc.edu
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Abstract |
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Methods: One hundred one women had bladder neck suspensions. Suprapubic catheters were used in 94 women and intermittent self-catheterization in seven to manage urinary retention after surgery. We used a standardized protocol to record days to adequate postoperative voiding. Univariable and multivariable regression analyses were used to determine clinical, urodynamic, and surgical factors that independently influenced time to adequate postoperative voiding.
Results: Women met the criteria for adequate voiding a mean of 7.1 days after modified open Burch procedures (n = 43), 9.5 days after anterior colporrhaphies with suburethral plication (n = 24), and 19.1 days after vaginal wall sling procedures (n = 34). The type of bladder neck suspension was independently associated with increasing time to void (P = .001). Multivariable regression analysis determined other factors significantly associated with longer time to adequate postoperative voiding: advancing age, previous vaginal bladder neck suspension, increasing volume at first sensation on bladder filling, higher postvoid residual urine volume (preoperative), and postoperative cystitis. Detrusor pressure, abdominal straining on pressure flow voiding study, and other concurrent surgeries were not significantly associated with postoperative voiding time in this model.
Conclusions: Time to adequate voiding after bladder neck suspension was influenced by type of surgical procedure, postoperative cystitis, and several demographic and urodynamic factors. This study does not support using pressure flow studies to predict women at risk of voiding dysfunction.
Normal voiding is commonly delayed after surgery for genuine stress urinary incontinence (GSUI). The incidence of voiding difficulties after colposuspension varies widely in the literature, although women rarely are unable to void after 30 days.1,2 Lose et al found that colposuspension might change the original micturition pattern and introduce an element of obstruction that can disturb the balance between voiding forces and outflow resistance, resulting in immediate postoperative and late voiding difficulties.3
Urodynamic tests have predicted early postoperative voiding difficulties.4,5 In particular, women with pressure flow voiding studies that showed absent detrusor contraction or Valsalva voiding patterns were at risk of postoperative voiding dysfunction.5 Bhatia and Bergman found that women with adequate detrusor contraction and flow rates on pressure flow voiding studies preoperatively were able to resume spontaneous voiding by the seventh postoperative day after Burch colposuspension.5 In contrast, no women with decreased flow rates and absent detrusor contraction during pre-operative voiding studies were able to void in fewer than 7 days postoperatively. They theorized that a Valsalva maneuver during voiding might predispose women to postoperative voiding difficulties by intensifying obstruction at the bladder neck. Other urodynamic factors such as preoperative uroflometry and postvoid residual urine volume measurement did not predict postoperative voiding difficulties after Burch colposuspension.6 However, previous studies have not assessed type of surgery as an independent risk factor of postoperative voiding dysfunction.
The aim of this prospective cohort study was to more accurately determine the times to normal voiding in women after three surgeries for GSUI. Multiple clinical, urodynamic, and surgical factors that might affect voiding independent of bladder neck suspension surgery were examined and analyzed as continuous variables using a multivariable regression model. Postoperatively, daily micturition diaries of voided and postvoid residual urine volumes were used to determine the return of normal voiding more accurately.
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Materials and Methods |
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Diagnostic urodynamic evaluation consisted of uroflometry, multichannel cystometry with provocation leak-point pressure measurements, and a pressure flow voiding study. Vaginal packing or pessaries were used to reduce pelvic organ prolapse, if necessary, during the urodynamic tests. Abdominal leak-point pressures were measured at every 50 mL of bladder volume starting at 150 mL and at bladder capacity. A pressure flow voiding study was done with women sitting on the uroflow chair at cystometric capacity after the cystometrogram and leak-point pressures were completed. Unless otherwise stated, the methods, definitions, and units conform to the standards proposed by the International Continence Society.9
Based on the urodynamic and clinical evaluations, anterior vaginal wall and bladder neck suspension procedures were done for diagnoses of cystocele and GSUI. Vaginal hysterectomy, suspension of vaginal vault to ileococcygeal fascia or sacrospinous ligament, enterocele repair, and posterior colporraphy in various combinations were the treatments for pelvic organ prolapses.
Bladder neck suspension procedures were based on these guidelines: anterior colporrhaphy with plication of endopelvic fascia below the urethra was done for cystocele and urethral hypermobility, but not for clinical or potential GSUI. Vaginal wall sling urethropexies were done for women with potential genuine stress urinary incontinence associated with significant vaginal prolapse that required vaginal repair.10 Burch colposuspension was done for GSUI with mild to moderate degrees of anterior vaginal wall relaxation and mild to moderate vaginal prolapse. Any procedure that mandated a laparotomy for other gynecologic indications involved a Burch colposuspension.
The surgical technique for anterior colporraphy with suburethral plication comprised interrupted plication sutures of the periurethral fascia as described by Walters and Karram.11 For the modified Burch procedure we used the technique of Tanagho.11,12 For the sling procedure we used the technique of Karram et al, using a patch of vaginal epithelium placed at the urethrovesical junction and attached to rectus fascia. A cotton swab was placed in the urethra while we secured the sling to assure minimal sling tension.11,13
Suprapubic catheters were placed during surgery and connected to a continuous drainage system until women were ambulatory. Voiding trials were done after clamping of the suprapubic catheter. Voided volumes were measured and recorded on micturition diaries. Discharge from the hospital was not influenced by postoperative voiding function. Intermittent self-catheterization was used postoperatively by women or physician choice, if suprapubic catheterization was contraindicated, if the suprapubic catheter malfunctioned, or if the skin insertion site became infected or painful before women could adequately void. After voiding, intermittent self-catheterization was done to determine the postvoid residual volume. All voided and postvoid residual volumes were measured and recorded on postoperative micturition diaries.
Suprapubic catheter or intermittent self-catheterization was discontinued after women showed adequate postoperative voiding, for which the criteria were: woman able to void spontaneously on each attempt and void more than 150 mL at least 75% of the time; the postvoid residual volumes less than 50% of the voided volume at least 75% of the time; voiding without pain; voiding without gross hematuria. The day that adequate postoperative voiding resumed was recorded based on diaries and not the day the suprapubic catheter was removed.
The primary outcome variable of interest was time to return of normal voiding postoperatively, measured in days since surgery. Linear regression models were used to assess the association between voiding time and known risk factors, plus other potential factors in three categories: demographic and medical characteristics, urodynamic variables, and surgical procedures. To meet distributional assumptions required for linear regression analyses, we used the natural log of voiding time as the outcome variable. In all cases, factors measured on a continuous scale were analyzed as continuous variables. First, univariable (single factor) associations with postoperative time to normal voiding were examined for each potential predictor variable, and interactions were explored. Based on those results several multivariable models were developed to assess the effect of each factor while controlling for the others. All statistical tests were two-tailed, and P < .05 was considered statistically significant. This study was approved by the institutional review board of the The Cleveland Clinic Foundation.
We used estimates from the literature to determine that 35 women per group would provide 90% power with a type I error rate of 0.05/3 = 0.017 to account for three pairwise comparisons. Estimates were based on assumed mean voiding times of 3.9, 5.1, and 16.3 days and a common standard deviation (SD) of 13.9.
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Results |
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. After clinical and urodynamic evaluation, 59 women had cystoceles to the hymen or beyond (grade II), and 39 had grade II or greater cervical or vaginal vault prolapses. Twenty-five had grade II or greater rectoceles. Sixty-one women had diagnoses of GSUI, 12 had mixed incontinence, and seven had detrusor instability alone but had surgery for symptomatic prolapse. Eighteen women had no incontinence and were operated on for pelvic organ prolapse. Forty-three had GSUI with pelvic organ prolapse greater or equal to grade II. Demographic characteristics by surgical type are listed in Table 2.
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There was a significant difference in voiding times among the three surgery groups (P < .001). Sling subjects had significantly longer voiding times than Burch or suburethral plication subjects (Table 3).
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), multivariable analysis was done. We analyzed factors from the seven study categories: demographics, uroflow, cystometrogram, pressure flow voiding, diagnosis, pelvic organ prolapse, and surgery. Among the groups of factors that belonged to each of the seven categories, the only factor that accounted for a significant portion of the variability was the type of surgical procedure (R2 = 0.434; Table 5).
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Discussion |
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Data on the pubovaginal sling techniques indicate that there is a higher rate of voiding dysfunction associated with those procedures. Incidence of voiding dysfunction after sling varies depending on the definition of delayed voiding. The incidence of voiding dysfunction ranges from 2.2% to 17%.17–19 The average time of postoperative catheterization has ranged from 11 to 60 days. Long-term voiding dysfunction (greater than 90 days) has been reported in 1–9% of patients.17 Weinberger et al reported that the presence of a detrusor contraction was associated with a shorter time to normal postoperative voiding, but that finding did not reach statistical significance.18 Women with persistent voiding dysfunction had no statistically significant changes in preoperative voiding mechanism than those without voiding dysfunction. Iglesia et al were able to detect a trend to longer voiding times in women who voided by Valsalva alone compared with those with other voiding patterns (23 versus 14 days, P = .049).20 However, McLennan et al were not able to detect an association between preoperative pressure flow voiding data and voiding time.21 Their data indicated an association between age older than 65 years and uroflow rates of less than 20 mL/second. Moreover, it is problematic to compare the various studies on voiding dysfunction after sling procedures because techniques often vary significantly.
Although our study did not meet its power requirements, we evaluated the factors that influence return to normal voiding after three common incontinence procedures. We attempted to identify any factor that might predict which women were at risk of voiding dysfunction. Factors associated with longer voiding times included increasing volume at first sensation on bladder filling, higher preoperative postvoid residual volumes, and postoperative cystitis. Those factors were not consistent between the three procedures studied. The finding of cystitis influencing voiding times also contradicted Bhatia and Bergman who did not find it a significant factor in return to normal voiding.5 We also analyzed three variables reported previously as associated with voiding times, Q-max, detrusor pressure change on pressure flow voiding, and preoperative postvoid residual volume, and found no association with the return to normal voiding on multivariable analysis. We found no significant relation between preoperative voiding mechanism and voiding time for any of the three procedures.
The results of our analyses were that voiding time depends primarily on the type of surgery. That relation remained strong even after we adjusted for effects of all other factors studied. However, after considering all factors, significant variability in voiding time could not be explained fully. That indicates that factors not included in the analysis affect voiding time or that considerable measurement error exists in determining return to normal voiding.
Our data seem to contradict some commonly accepted beliefs about postoperative voiding dysfunction; however, the analysis points to a more important conclusion, that changes in the voiding mechanism after incontinence surgery are most influenced by type of surgery used to treat GSUI.
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Footnotes |
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Received February 29, 2000. Received in revised form July 28, 2000. Accepted September 28, 2000.
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References |
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2. Korda A, Ferry J, Hunter PL. Colposuspension for the treatment of female urinary incontinence. Aust NZ J Obstet Gynaecol 1989;29: 146–9.[Medline]
3. Lose G, Jorgensen L, Mortensen SO. Voiding difficulties after colposuspension. Obstet Gynecol 1987;69:33–8.
4. Bhatia N, Bergman A. Urodynamic predictability of voiding following incontinence surgery. Obstet Gynecol 1984;63:85–91.
5. Bhatia N, Bergman A. Use of preoperative uroflowmetry and simultaneous urethrocystometry for predicting risk of prolonged postoperative bladder drainage. Urology 1986;28:440–5.[Medline]
6. Bergman A, Bhatia N. Uroflowmetry for predicting postoperative voiding difficulties in women with stress urinary incontinence. Br J Obstet Gynaecol 1985;92:835–8.[Medline]
7. Baden WF, Walker T. Fundamentals, symptoms and classification. In: Baden WF, Walker T, eds. Surgical repair of vaginal defects. Philadelphia: J.B. Lippincott, 1992:14.
8. Walters MD, Diaz K. Q-tip test: A study of continent and incontinent women. Obstet Gynecol 1987;70:208–11.
9. Abrams P, Blaivas JG, Stanton SL, Anderson JT. The standardization of terminology of lower tract function. Scand J Urol Nephrol 1988;114(suppl):5–19.
10. Hilton P. A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence. Br J Obstet Gynaecol 1989;96:213–20.[Medline]
11. Walters MW, Karram MM. Clinical urogynecology. St. Louis, Missouri: Mosby-Year Book, 1993:229–30.
12. Tanagho EA. Colpocystourethropexy: The way we do it. J Urol 1976;116:751–3.[Medline]
13. Karram M. Modified transvaginal fascia lata sling. J Pelvic Surg 1996;2:134–7.
14. Sze E, Miklos J, Karram M. Voiding after Burch colposuspension and effects of concomitant pelvic surgery: Correlation with preoperative voiding mechanism. Obstet Gynecol 1996;88:564–7.[Abstract]
15. Smith R, Cardozo L. Early voiding difficulty after colposuspension. Br J Urol 1997;80:911–4.[Medline]
16. Beck RP, McCormick S, Nordstron L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol 1991;78: 1011–8.
17. Beck RP, NcCormick S, Nordstron L. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Obstet Gynecol 1988;72:699–703.
18. Weinberger MW, Ostergard D. Postoperative catheterization, urinary retention and permanent voiding dysfunction after polytetrfluoroethylene suburethral sling placement. Obstet Gynecol 1996; 87:50–4.[Abstract]
19. McGuire ED, Bennet CJ, Konnak JA, Sonda P, Savastano JA. Experience with pubovaginal slings for urinary incontinence at the University of Michigan. J Urol 1987;138:525–6.[Medline]
20. Iglesia C, Shott S, Fenner D. Effect of preoperative voiding mechanism on success rate of autologous rectus fascia suburethral sling procedure. Obstet Gynecol 1998;91:577–81.[Abstract]
21. McIennan M, Melick C, Bent A. Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling. Obstet Gynecol 1998;92:608–12.[Abstract]
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