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Survey of Voiding Dysfunction and Urinary Retention After Anti-Incontinence Procedures

From the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics & Gynecology, Kaiser Foundation Hospital, Bellflower; and the Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics & Gynecology, Harbor-UCLA Medical Center, UCLA School of Medicine, Torrance, California.

Address reprint requests to: John K. Nguyen, MD, Division of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Kaiser Foundation Hospital, 9449 E. Imperial Highway, Suite C337, Downey, CA 90242; E-mail: john.n.nguyen{at}kp.org.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
OBJECTIVE: To describe trends in the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures.

METHODS: Physician members of the American Urogynecologic Society were queried by means of a two-page questionnaire regarding the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures.

RESULTS: A total of 344 (42%) of 825 questionnaires were completed and returned. Of the 344 respondents, 61% identified themselves as urogynecologists, 50% worked in a university-affiliated practice, and 26% had been in practice for 11–20 years. Respondents rarely encountered prolonged urinary retention after anti-incontinence procedures. Among the respondents, 30% allowed 3–6 months for resumption of spontaneous voiding before performing surgical revision, and 90% performed multichannel urodynamic studies before surgical revision. However, 66% performed surgical revision transabdominally when urinary retention occurred after retropubic urethropexy, and 61–81% of respondents performed surgical revision transvaginally when urinary retention followed needle suspension, pubovaginal sling, or tension-free vaginal tape procedures. A total of 90–96% did not perform an anti-incontinence procedure concomitantly with surgical revision. The majority of respondents reported spontaneous voiding in greater than 80% of patients, and recurrent stress urinary incontinence in less than 10% of patients after surgical revision.

CONCLUSION: Although certain trends in the management of prolonged urinary retention after anti-incontinence procedures were identified, there was no clear consensus on the method of surgical revision used, nor the management of recurrent stress urinary incontinence after surgical revision. Randomized clinical trials are required to determine the optimal management of prolonged urinary retention after anti-incontinence procedures.

Voiding dysfunction occurs in up to 25% of patients after anti-incontinence operations.¹ It is difficult to ascertain the true incidence of voiding dysfunction as the definition varies from poor stream to that requiring intermittent self-catherization. Postoperative urinary retention is usually transient and can be treated with an indwelling catheter or by intermittent self-catheterization until resumption of spontaneous voiding has occurred. Prolonged urinary retention that has not responded to conservative treatment may eventually require surgical intervention. Up to 8% of women may require long-term self-catheterization after pubovaginal sling procedures.¹

Many surgical procedures have been described to treat urinary retention caused by bladder neck obstruction after anti-incontinence procedures. Removal of suspension sutures is feasible when performed before permanent fixation of the urethra in the retropubic space has occurred. However, sharp dissection and mobilization of the urethra and bladder neck from the pubic ramus may be required to relieve bladder neck obstruction once permanent fixation of the urethra in the retropubic space has occurred. Resumption of spontaneous voiding occurs in 33–100% of patients after urethrolysis.^2–11 Incision of the suburethral portion of a pubovaginal sling and interposition of a vaginal flap between the free ends can also relieve urethral obstruction and provide bladder neck support.^12,13 Alternatively, pubovaginal sling release from its attachment to the rectus fascia has also been described.¹⁴ The efficacy of these procedures is limited to case reports and case series. The purpose of this study was to describe trends in the management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures among physician members of the American Urogynecologic Society.

	MATERIALS AND METHODS

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The American Urogynecologic Society is an international medical society, consisting of medical practitioners from several countries and different medical specialties dedicated to advancing the care of women with pelvic floor dysfunction. At the time this survey was performed, the American Urogynecologic Society consisted of 852 members. Because we wanted to investigate trends in the surgical management of prolonged voiding dysfunction and urinary retention after anti-incontinence procedures, we surveyed only physician members of the American Urogynecologic Society. Physician members (n = 825) were queried by means of an anonymous two-page questionnaire using address labels obtained from the Society. Questionnaires were not sent to nonphysican members (n = 27).

Data from the questionnaires were collected and analyzed. The survey included questions regarding the physicians’ practice type, practice setting, as well as length of time in practice. Physicians were queried about their lifetime experience with anti-incontinence procedures, which included retropubic urethropexy (ie, Burch urethropexy, Marshall-Marchetti-Krantz procedure), transvaginal needle suspension (ie, modified Pereyra, Raz, Stamey, Gittes, etc), pubovaginal sling, and tension-free vaginal tape (ETHICON INC., Johnson & Johnson, Somerville, NJ) procedures. Data including the incidence of prolonged postoperative urinary retention, defined as an inability to void greater than or equal to 30 days postoperatively necessitating an indwelling catheter or intermittent self-catherization, and the incidence of urinary retention requiring surgical revision were collected. In addition, physicians were queried about the surgical method used to treat postoperative bladder neck obstruction and the rates of spontaneous voiding after surgical revision. Lastly, physicians were queried about the management of persistent urinary retention and/or recurrent stress urinary incontinence after surgical revision. Statistics are descriptive.

	RESULTS

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The two-page questionnaires were mailed to 825 physician members of the American Urogynecologic Society. However, 29 (3%) surveys were returned because of incorrect addresses, and 445 (54%) members did not respond. Seven (1%) physicians were retired at the time of the survey, did not complete the survey, and were not included in the current study. A total of 344 (42%) questionnaires were completed and returned. Of the 344 responding physicians, 209 (61%) identified themselves primarily as urogynecologists, whereas 111 (32%) described themselves as obstetrician-gynecologists and 14 (4%) as urologists. Most worked in either a university-affiliated (n = 172, 50%) or private practice (n = 151, 44%). A minority were employed by a health maintenance organization (n = 9, 2.5%) or the military (n = 2, 0.5%). The length of time in practice was reported by 300 (87%) of the 344 respondents, whereas 34 (10%) of the 344 respondents reported demographic information with the exception of the length of time in practice. Of the 344 respondents, 72 (21%), 71 (21%), 91 (26%), and 66 (10%) had been in practice for less than 5 years, from 5 to 10 years, from 11 to 20 years, and greater than 20 years, respectively. Ten (3%) of the 344 respondents did not report any demographic information but completed the rest of the survey.

Lifetime numbers of anti-incontinence procedures performed by respondents are listed in Table 1. Retropubic urethropexy was performed by all but one of the respondents. Also, 41% had performed more than 50 sling procedures. Of the 290 physicians performing pubovaginal sling procedures, 72 (25%) used synthetic nonabsorbable sling materials, whereas 218 (75%) used either autologous rectus fascia or cadaveric fascia lata or dermis. Transvaginal needle procedures were not commonly performed with only 21% of respondents having performed more than 50 needle procedures. Very few respondents (9%) had performed more than 50 tension-free vaginal tape procedures.

There was no consensus on the time allowed for resumption of spontaneous voiding after anti-incontinence procedures before performing surgical revision. Among the respondents, 30% (n = 103) allowed between 3–6 months, 13% (n = 45) waited less than 3 months, and 9% (n = 31) conservatively treated patients between 7–12 months before performing surgical revision. However, 48% (n = 165) did not specify the length of time allowed for spontaneous voiding to resume before proceeding with surgical revision. Of the 344 respondents, 308 (90%) performed multichannel urodynamic studies before surgical revision, 15 (4%) did not, and 21 (6%) did not answer the question.

Surgical methods used to treat prolonged urinary retention are presented in Table 2. A minority of respondents preferred a combined transabdominal and transvaginal approach. Most respondents (66%) preferred a transabdominal approach when urinary retention followed a previous retropubic urethropexy. Whereas 47% removed only the suspension sutures, 49% performed retropubic urethrolysis with removal of suspension sutures as well. Also, 9% performed an anti-incontinence procedure at the time of surgical revision when urinary retention followed a previous retropubic urethropexy.

When urinary retention followed a pubovaginal sling or tension-free vaginal tape procedure, 81% preferred a transvaginal approach. However, there was no consensus on the type of procedure performed. Excision/incision of the suburethral portion of the pubovaginal sling or tension-free vaginal tape was performed by 53% and 55%, respectively. Of those respondents preferring to excise/incise the suburethral portion of the pubovaginal sling or tension-free vaginal tape, 12 of 116 (10%) and five of 62 (8%) interposed a tissue graft (fascia lata or vaginal mucosa) between the free ends to lengthen the pubovaginal sling or tension-free vaginal tape, respectively. Excision of one or both arms of the pubovaginal sling or tension-free vaginal tape was performed by 15% and 13%, respectively. Urethrolysis with removal of the pubovaginal sling or tension-free vaginal tape was performed by 14% and 16%, respectively. The decision to perform urethrolysis versus incision of the sling (suburethral portion or sling arms) was not dependent upon the type of sling material used (absorbable versus nonabsorbable). Most respondents did not perform an anti-incontinence procedure with urethrolysis when urinary retention followed a pubovaginal sling or tension-free vaginal tape procedure.

Respondents were asked if they interposed a barrier in the retropubic space at the time of surgical revision to prevent urethral adherence to the pubic ramus. Whereas 92% (n = 316) did not interpose a barrier in the retropubic space at the time of surgical revision, 4% (n = 14) interposed a Martius fat pad between the urethra and pubic ramus. Rarely did respondents interpose omentum (n = 8, 2%) or other materials, such as Interceed (ETHICON INC., Johnson & Johnson, Somerville, NJ), Seprafilm (Genzyme Biosurgery, Cambridge, MA), or vaginal mucosa (n = 6, 2%), between the urethra and pubic ramus at the time of surgical revision.

The rates of spontaneous voiding after surgical revision are presented in Figure 1. The majority of respondents reported spontaneous voiding in greater than 80% of patients after surgical revision. A smaller proportion reported spontaneous voiding in 41–80% of patients after surgical revision. Very few respondents reported spontaneous voiding rates of less than 40% after surgical revision. The rate of spontaneous voiding was not affected by the method of surgical revision used.

View larger version (35K): [in this window] [in a new window]   Figure 1. Reported rate of spontaneous voiding after surgical revision. TVT = tension-free vaginal tape (ETHICON INC., Johnson & Johnson, Somerville, NJ). Nguyen. Postoperative Urinary Retention. Obstet Gynecol 2001.

The incidence of recurrent stress urinary incontinence after surgical revision is presented in Figure 2. Overall, 62–70% reported recurrent stress urinary incontinence in less than 10% of patients after surgical revision. When surgical revision was performed for urinary retention after previous tension-free vaginal tape procedure, 21% reported recurrent stress urinary incontinence in greater than 50% of patients after surgical revision. In contrast, only 1–2% reported recurrent stress urinary incontinence in greater than 50% of patients after surgical revision for urinary retention occurring after previous retropubic urethropexy, needle suspension, or pubovaginal sling procedure.

View larger version (34K): [in this window] [in a new window]   Figure 2. Reported rate of recurrent stress urinary incontinence after surgical revision. TVT = tension-free vaginal tape (ETHICON INC., Johnson & Johnson, Somerville, NJ). Nguyen. Postoperative Urinary Retention. Obstet Gynecol 2001.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Neither prolonged urinary retention nor urinary retention requiring surgical revision was commonly encountered by responding physician members of the American Urogynecologic Society. When we inquired about the incidence of prolonged urinary retention and urinary retention requiring surgical revision, we did not differentiate between patients with urinary retention referred to respondents by other physicians, and those primarily operated upon by the respondents themselves. Because some physicians practiced in a referral center, it is possible for those physicians to have treated a higher number of patients with prolonged urinary retention than other physicians. Nonetheless, the overall incidences of prolonged urinary retention and urinary retention requiring surgical revision were both low.

The diagnosis and management of bladder neck obstruction and urinary retention after anti-incontinence procedures are often challenging. Elevated detrusor pressure and low urinary flow rate during voiding pressure flow studies are indicative of bladder neck obstruction. However, urodynamic studies occasionally may not be useful in differentiating between patients with bladder neck obstruction and patients without bladder neck obstruction. As a result, bladder neck obstruction after anti-incontinence procedures is sometimes diagnosed by history (ie, onset of obstructive voiding symptoms after the anti-incontinence procedure in a patient without preoperative symptoms) and physical examination (fixed urethra in a high retropubic position) without confirmation by urodynamic studies. Additionally, no single urodynamic parameter has been consistently demonstrated to be predictive of outcome after urethrolyis.^4,5,9–11 Despite its uncertain diagnostic and prognostic efficacy in the evaluation of women with bladder neck obstruction, the majority of respondents believed it was necessary to perform multichannel urodynamic studies before surgical revision to fully evaluate detrusor and urethral function.

For most respondents, the type of anti-incontinence procedure leading to urinary retention dictated the route of surgical revision chosen. As a result, a transabdominal approach was generally preferred when urinary retention followed a retropubic urethropexy, and a transvaginal approach was preferred when urinary retention followed transvaginal anti-incontinence procedures. This trend was most evident when urinary retention followed pubovaginal sling or tension-free vaginal tape procedures.

In contrast to the trend observed in the route of surgical revision chosen, there was no consensus on the surgical method chosen to treat prolonged urinary retention after anti-incontinence procedures. A variety of surgical procedures were used to treat prolonged urinary retention. The preference of certain procedures over other procedures was unclear. However, respondents generally preferred less invasive surgical procedures over urethrolysis. Removal of suspension sutures was generally preferred when urinary retention followed retropubic urethropexy or needle suspension and generally resulted in high rates of spontaneous voiding. When urinary retention followed a pubovaginal sling or tension-free vaginal tape procedure, most respondents preferred to incise the suburethral portion of the sling or tension-free vaginal tape, and occasionally interposed fascia lata or vaginal mucosa between the free ends to lengthen the sling or tension-free vaginal tape. Many respondents preferred this surgical approach despite studies demonstrating its efficacy involved only a handful of patients.^12,13

Although high rates of spontaneous voiding in women with urinary retention caused by bladder neck obstruction after anti-incontinence procedures has been reported to occur after both transabdominal and transvaginal urethrolysis,^2–11 few respondents preferred this surgical approach. Respondents performed urethrolysis commonly for urinary retention after retropubic urethropexy, but less often for urinary retention after needle suspension, pubovaginal sling, or tension-free vaginal tape procedures. In women with urinary retention after pubovaginal sling or tension-free vaginal tape procedures, preference for sling or tension-free vaginal tape incision (with or without tissue graft interposition) over urethrolysis with complete sling or tension-free vaginal tape excision may be secondary to the perceived higher surgical morbidity and risk of recurrent stress urinary incontinence associated with the latter surgical procedure.

Excessive urethral hypermobility and recurrent stress urinary incontinence occur in up to 19.3% of patients after urethrolysis.^2–11 Performing an anti-incontinence procedure with urethrolysis may decrease the risk of recurrent stress urinary incontinence but can also cause persistent urinary retention. To date, the value of performing an anti-incontinence procedure with urethrolysis for potential recurrent stress urinary incontinence in continent women with bladder neck obstruction after anti-incontinence procedures has not been adequately evaluated.^2–11 The majority of respondents in this study did not perform an anti-incontinence procedure with urethrolysis.

Recurrent stress urinary incontinence occurred uncommonly after surgical revision. Recurrent stress urinary incontinence occurred most commonly after surgical revision of previous tension-free vaginal tape procedures and may be related to the lack of retropubic dissection and thus minimal retropubic scarring associated with this procedure. There was no consensus among respondents on how to treat patients with recurrent stress urinary incontinence after surgical revision. A variety of nonsurgical therapy and surgical procedures were used by respondents to treat patients with recurrent stress urinary incontinence after surgical revision.

Persistent bladder neck obstruction and urinary retention after urethrolysis can occur as a result of readherence of the urethra to the pubic ramus. An omental pedicle or Martius fat pad can be placed onto the denuded surface during urethrolysis to prevent adherence of the urethra to the pubic ramus. Only 8% of respondents interposed a Martius fat pad, ometum, or other barriers between the urethra and pubic ramus at the time of urethrolysis. Generally, omentum was preferred with transabdominal approaches, and a Martius fat pad was preferred with transvaginal approaches. To date, the value of interposing a barrier to prevent readherence of the urethra to the pubic bone has not been adequately studied.

Respondents generally agreed upon the management of persistent urinary retention after surgical revision. A total of 92% continued intermittent self-catheterization in patients with persistent urinary retention after surgical revision. Other nonsurgical modalities, such as biofeedback and pharmacotherapy, were not commonly used. This may reflect the lack of proven efficacy of such modalities in the treatment of prolonged urinary retention after anti-incontinence procedures. Only 5% repeated urethrolysis or used the Interstim Continence Control System.

The survey identified both clearly defined similarities and differences in opinion among responding physician members of the American Urogynecologic Society regarding the management of prolonged urinary retention after anti-incontinence procedures. Because only 42% of the physicians surveyed responded, it is unclear if the practice trends described in this study were representative of those of the Society as a whole. As most of the outcomes reported were subjective and based on physician recall, significant bias is a concern. Questionnaires were not remailed to nonrespondents, and the high number of nonrespondents could have also biased our results.

We realize that the management of patients with prolonged urinary retention after anti-incontinence procedures should be taken on a case-by-case basis and cannot be generalized. It was our intent to describe trends in the management of prolonged urinary retention after anti-incontinence procedures among physician members of the American Urogynecologic Society. It was not our intent to determine treatment guidelines. As a result, this survey did not establish the optimal approach to the preoperative assessment of women with prolonged urinary retention after anti-incontinence procedures, nor did it establish a clinical guideline for selecting the best surgical procedure for any given patient. Current surgical management of prolonged urinary retention after anti-incontinence procedures is based mainly upon retrospective case reports and case series.^2–14 Randomized prospective clinical trials are required to determine the optimal surgical treatment of prolonged postoperative voiding dysfunction and urinary retention.

	Footnotes

 
PII S0029-7844(01)01568-X

Received February 6, 2001. Received in revised form July 10, 2001. Accepted July 19, 2001.

	REFERENCES

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Chaliha C, Stanton SL. Complications of surgery for genuine stress incontinence. Br J Obstet Gynaecol 1999; 106:1238–45.[Medline]

2. Zimmern PE, Hadley HR, Leach GE, Raz S. Female urethral obstruction after Marshall-Marchetti-Krantz operation. J Urol 1987;138:517–20.[Medline]

3. McGuire EJ, Letson W, Wang S. Transvaginal urethrolysis after obstructive urethral suspension procedures. J Urol 1989;142:1037–9.[Medline]

4. Foster HE, McGuire EJ. Management of urethral obstruction with transvaginal urethrolysis. J Urol 1993;150: 1448–51.[Medline]

5. Nitti VW, Raz S. Obstruction following anti-incontinence procedure diagnosing and treatment with transvaginal urethrolysis. J Urol 1994;152:93–8.[Medline]

6. Austin P, Evangelos S, Lotenfoe R, Helal M, Hoffman M, Lockhart JL. Urethral obstruction after anti-incontinence surgery: Evaluation, methodology, and surgical results. Urology 1996;47:890–4.[Medline]

7. Goldman HB, Rackley RR, Appell RA. The efficacy of urethrolysis without resuspension for iatrogenic urethral obstruction. J Urol 1999;161:196–9.[Medline]

8. Webster GD, Kreder KJ. Voiding dysfunction following cystourethropexy: Its evaluation and management. J Urol 1990;144:670–3.[Medline]

9. Carr LK, Webster GD. Voiding dysfunction following incontinence surgery diagnosis and treatment with retropubic or vaginal urethrolysis. J Urol 1997;157:821–3.[Medline]

10. Cross CA, Cespedes D, English SF, McGuire EJ. Transvaginal urethrolysis for urethral obstruction after anti-incontinence surgery. J Urol 1998;159:1199–201.[Medline]

11. Petrou SP, Brown JA, Blaivas JG. Suprameatal transvaginal urethrolysis. J Urol 1999;161:1268–71.[Medline]

12. McLennan MT, Bent AE. Sling incision with associated vaginal wall interposition for obstructed voiding secondary to suburethral sling procedure. Int Urogynecol J 1997; 8:168–72.[Medline]

13. Ghoniem GM, Abdel-Nasser E. Simplified surgical approach to bladder outlet obstruction following pubovaginal sling. J Urol 1995;154:181–3.[Medline]

14. Brubaker L. Suburethral sling release. Obstet Gynecol 1995;86:686–8.[Abstract]

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