Female Urethral Obstruction After Marshall-Marchetti-Krantz Operation

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FEMALE URETHRAL OBSTRUCTION AFTER iVIARSHALLMARCHETTI-aKRANTZ OPERATION P. K ZIMMERN,* H. R HADLEY, G. E. LEACH

AND

SHLOMO RAZ

From the Departments of Surgery/Urology, UCLA School of Medicine, Loma Linda University and Kaiser Permanente, Los Angeles, California

ABSTRACT

During the last 5 years 13 neurologically normal women were seen with urodynamically proved urethral obstruction after a Marshall-Marchetti-Krantz operation. These obstructed patients were treated by a simple transvaginal procedure consisting of complete urethrolysis followed by a needle urethrovesical resuspension procedure. Postoperatively, 12 patients experienced complete disappearance of the presenting symptoms, return to a normal voiding pattern and decreased residuals of urine to less than 50 cc. The remaining patient, although urodynamically unobstructed, had to remain on intermittent catheterization. The pathophysiology, diagnosis and treatment of this iatrogenic type of female urethral obstruction are discussed. (J. Ural., 138: 517-520, 1987) pubic space. The polypropylene sutures are transferred to the suprapubic position. Cystoscopy is performed to confirm satisfactory suspension of the proximal urethra and bladder neck, absence of suture entry into the bladder or urethra and efflux from each ureteral orifice of pre-administered intravenous indigo carmine. These sutures are tied separately over the rectus muscle and then to the contralateral ones across the midline. The vaginal incision is closed and a vaginal packing is inserted. Postoperative care included removal of the Foley catheter and vaginal packing after 24 hours. The patient was started immediately on intermittent self-catheterization until 2 consecutive bladder residuals were less than 50 to 100 cc. The patient then was seen for regular followup at 2 weeks, 3 months and 6 months. Repeat urodynamic evaluation was undertaken to determine persistent symptomatology or elevated post-void residuals.

Since its original description in 1949, the MarshallMarchetti-Krantz operation has become one of the most common procedures performed to achieve urethrovesical suspension for the treatment of stress urinary incontinence. 1 Although it is now recognized more frequently, urethral obstruction leading to persistent retention of urine remains an uncommon postoperative complication, with an incidence of 5 to 20 per cent. 2- 4 We describe 13 neurologically normal women seen during the last 5 years with radiographically and urodynamically proved urethral obstruction after a Marshall-MarchettiKrantz operation. This condition was corrected by a simple transvaginal procedure consisting of complete urethrolysis, 5 followed by a needle urethrovesical resuspension. 6 • 7 MATERIAL AND METHODS

The charts of 13 neurologically normal patients who were evaluated for urethral obstruction after a Marshall-MarchettiKrantz operation between January 1981 and December 1984 were studied retrospectively. Clinically, the patients presented with stress incontinence alone (3), stress incontinence associated with frequency and urgency (4), urinary tract infection (4) or complete urinary retention that required intermittent selfcatheterization (2). A detailed history was obtained to document prior modalities of treatment and the length of time elapsed since the operation. A complete urodynamic evaluation, including uroflowmetry, medium water filling cystometry (in supine and standing positions with provocative maneuvers), pressure-flow study, cystoscopy and voiding cystourethrogram, was performed in all patients. Methods, definitions and units conformed to the standards proposed by the International Continence Society. Transvaginal urethrolysis followed a needle bladder neck suspension was performed in all patients. An inverted U shape incision is made in the anterior vaginal wall. The endopelvic fascia is entered bluntly or sharply on each side of the bladder neck but lateral to it. Urethrolysis is done to free completely the bladder neck and proximal urethra from previous retropubic and periurethral adhesions and sutures. Bilateral placement of an helicoidal No. 1 polypropylene suture is placed in the endopelvic fascia and vaginal wall lateral to the bladder neck. Under constant fingertip guidance a long blunt needle is passed from the suprapubic area to the vaginal incision via the retroAccepted for publication February 12, 1987. Read at annual meeting of American Urological Association, Atlanta, Georgia, May 12-16, 1985. * Requests for reprints: Division of Urology, CHS 66-143, UCLA School of Medicine, 10833 Le Conte Ave., Los Angeles, California 90024.

RESULTS

Chart review revealed that the time elapsed from the Marshall-Marchetti-Krantz operation to our evaluation ranged from 1 to 6 years, with a mean of 3.5 years (table 1). According to the operative report 7 patients underwent the classical Marshall-Marchetti-Krantz repair. Whether the remaining 6 patients had the same type of operation or the modified procedure8 could not be assessed with certainty. In addition, all patients had been managed unsuccessfully by nonoperative means, combining urethral =•=v•~u,~, pharmacological therapy and/or intermittent self-catheterization. Urodynamic findings were consistent with an obstructive pattern of high true detrusor voiding pressure with a simultaneous low urinary flow rate ofless than 12 cc per second (table 2 and fig. 1). The flow curve usually was prolonged and interrupted, as illustrated by a mean voiding time of 119 seconds. The 2 patients on intermittent catheterization had a large bladder capacity (600 and 1,200 cc) with no evidence of uninhibited contractions, as well as high true detrusor voiding pressures that were sustained poorly, resulting in a long and interrupted uroflow curve. The volume voided remained at less than 150 cc for both patients. Cystoscopically, all 13 patients demonstrated good urethral support and mild to moderate bladder trabeculations. Precise evaluation of the amount of post-void residual urine was assessed routinely at the beginning of cystoscopy, and it ranged between 100 and 450 cc. Urethral deviation owing to the presence of a proximal or mid urethral suture was discovered during urethroscopy and/or on the voiding urethrogram in 5 patients (fig. 2). The source of urethral obstruction was attributed to periurethral scarring in the remaining 8 patients.

517

518

ZIMMERN AND ASSOCIATES TABLE 1

Prior Operations (yr.)

Pt. No.

Anterior colporrhaphy/abdominal hysterectomy (1968), Marshall-MarchettiKrantz (1977) Vaginal hysterectomy/ anterior colporrhaphy (1966), Marshall-Marchetti-Krantz (1977) Abdominal hysterectomy /MarshallMarchetti-Krantz (1978) Anterior colporrhaphy (1979), MarshallMarchetti-Krantz (1982) Abdominal hysterectomy (1971), Marshall-Marchetti-Krantz (1976) Abdominal hysterectomy (1972), Marshall-Marchetti-Krantz (1979) Vaginal hysterectomy/anterior colporrhaphy (1981), Marshall-Marchetti-Krantz (1982) Marshall-Marchetti- Krantz (1979) Marshall-Marchetti-Krantz (1982)

2 3

4 5 6

7

8 9

Abdominal hysterectomy (1965), Marshall-Marchetti-Krantz (1980) Abdominal hysterectomy /MarshallMarchetti-Krantz (1983) Abdominal hysterectomy/MarshallMarchetti-Krantz (1982) Marshall-Marchetti- Krantz (1980)

10 11

12 13

Presenting Symptoms

Onset of Stress Urinary Incontinence After childbirth

Stress urinary incontinence+ frequency, urgency

After anterior colporrhaphy

Stress urinary incontinence + frequency, urgency

After childbirth

Urinary tract infection

Before anterior colporrhaphy

After abdominal hysterectomy

Stress urinary incontinence + frequency, urgency Complete urinary retention/intermittent self-catheterization Stress urinary incontinence

After anterior colporrhaphy

Urinary tract infection

No cause reported No cause reported

Urinary tract infection Complete urinary retention/intermittent self-catheterization Stress urinary incontinence

After abdominal hysterectomy

After abdominal hysterectomy After Marshall-Marchetti-Krantz No cause reported

Stress urinary incontinence + frequency, urgency Urinary tract infection

No cause reported

Stress urinary incontinence

TABLE 2

Pt. No.-Age

Yrs. Elapsed Since Marshall-Marchetti-Krantz Operation

Post-Void Residual (cc)

True Detrusor Voiding Pressure (cm. water)

Voiding Time (sec.)

Flow (cc/sec.)

1-68 2-68 3-49 4-75 5-43 6-52 7-41 8-53 9-79 10-83 11-56 12-72 13-60

6 6 5 2 6 5 2 4 1 2 1 2 3

125 100 450 175 600 155 170 200 1,200 110 200 400 150

45 50 56 60 48 65 52 40 55 62 60 48 45

167 106 128 76 220 69 72 65 250 107 104 116 70

11.4 6.3 10.9 8.1 3.5 11.6 10.3 11.3 4.8 7.8 8.7 7.9 11.5

Followup ranged from 12 to 44 months (mean 20 months). No immediate or delayed perioperative complications were noted. Results were good in 12 of the 13 patients (92 per cent), with complete disappearance of symptoms, return of a normal voiding pattern and residuals of urine of less than 50 cc. Of the 2 patients originally performing self-catheterization 1 had absolutely no voiding improvement 3 months postoperatively. Repeat urodynamic evaluation showed a similar bladder capacity with good compliance and no uninhibited contractions during the filling phase. The voiding study demonstrated a good detrusor contraction although unsustained, which achieved better emptying than previously (postoperative residual of 300 cc versus preoperative 1,200 cc) and an improved flow (postoperative rate 11 cc versus preoperative 4.8 cc per second). At 1year followup there were no more urodynamic changes and the patient remained on intermittent catheterization. DISCUSSION

Urethral obstruction after bladder neck suspension is difficult to diagnose and it does not respond to standard methods of therapy, such as urethral dilations or pharmacotherapy. Although rare, this complication has been noted with increasing frequency following the Marshall-Marchetti-Krantz procedure. Sarramon and associates reported the development of permanent urinary retention in 7 of 100 patients after retropubic urethral suspension.4 In the series of McDuffie and associates 24 of 204 patients (11. 7 per cent) had chronic urinary retention

at 2-year followup. 2 Rost and associates noted persistent elevated residual urine values in 9 of 42 patients (21 per cent) followed for 61 months. 3 A simple explanation for this fairly high incidence of postoperative urethral obstruction after a Marshall-MarchettiKrantz operation for correction of urinary incontinence can be found in the original description of the technique in 1949. Number 1 sutures of chromic catgut were placed into the anterior vaginal wall and "through the lateral wall of the urethra, caution being exercised to avoid entering the urethral lumen ... ". 1 These sutures were placed on either side of the urethra and the bladder neck, and they were secured to the periosteum of the pubic bone and the cartilage of the symphysis. The description of the Marshall-Marchetti-Krantz technique subsequently was modified to avoid suture placement into the urethral wall. 8 In the patient treated by a Marshall-Marchetti-Krantz operation prolonged poor postoperative flow, high residual urine and the development of detrusor instability often have been viewed as acceptable postoperative results, since they were considered an improvement over the preoperative incontinence. Intermittent catheterization has been used to obviate the difficulties encountered with bladder emptying, and pharmacological inhibition of detrusor instability has been used to modify the symptoms of frequency and urgency. Urethral dilations also have been recommended with results varying from temporary relief to worsening of the urethral rigidity secondary to periurethral fibrosis.

519

81sddsr Pressure

Detrusor Prossure

~ 10cmH'O

C

:

III

I

FIG. 1. Patient 2 in tables. Urodynamic tracing characteristic of female outflow obstruction (high true detrusor pressure and poor flow).

submucosa and smooth as opposed fibrosis of the skeletal and pelvic floor muscles. After the diagnosis of iatrogenic organic urethral obstruction was established, we selected a transvaginal approach to allow for complete urethrolysis, and resuspension of the bladder neck and proximal urethra. 6 • 7 The advantages of this technique are 3-fold: 1) to avoid previous suprapubic areas of fibrosis and scarring that one would inevitably encounter through a repeat abdominal approach, 2) to allow for direct and safe access to any periurethral or anterior vaginal wall fibrosis or suture that must be released to alleviate the outflow obstruction and allow for an adequate bladder neck suspension,5 and 3) to restore the support of the proximal urethra and bladder neck after urethrolysis. This third goal can be achieved simply by transvaginal needle urethrovesical suspension, which allows for placement of new sutures in the vaginal wall lateral to the bladder neck to return the proximal urethra to a nonmobile, nonobstructive retropubic position. During the procedure it is important to examine for periurethral sutures that may have been missed during the preoperative assessment. For example, in 1 patient with a combination of stress incontinence and irritative symptomatology a mid periurethral suture was found, which clarified the unexplained preoperative obstructive urodynamic pattern. Stress incontinence was attributed in this case to improper suture placement resulting in lack of bladder neck support. In this small series postoperative disappearance of detrusor instability paralleled a classical phenomenon seen in male patients with irritative voiding symptoms relieved by prostatic resection. Therefore, symptoms of frequency and urgency secondary to documented iatrogenic urethral obstruction should be treated operatively to preserve detrusor function and to prevent upper urinary tract deterioration. Patients with preoperative evidence of bladder wall damage, presumably of myogenic origin as a result of long-standing chronic retention (over-stretched bladders), may retain some degree of bladder dysfunction despite postoperative urodynamic demonstration of an unobstructed voiding pattern. In a recent report by McGuire and Savastano, comparing the rate of postoperative detrusor instability after various operations to correct stress urinary incontinence, the lowest percentage was noted with the described procedure. 9 We believe that supporting sutures should be placed carefully in the endopelvic fascia and the vaginal wall at the level of the bladder neck and proximal urethra but lateral to them to avoid the periurethral structures, thereby diminishing the risks of intraurethral suture placement and periurethral fibrosis leading to urethral obstruction. 10' 11 After the needle urethrovesical suspension, the proximal urethra returns to a nonobstructive retropubic position where it can respond appropriately to abdominal pressure transmission. 6 • 12

CONCLUSION

FIG. 2. Patient 3 in tables. Voiding cystourethrogram demonstrates urethral distortion secondary to mid urethral suture that was seen at urethroscopy.

Voiding dysfunction, which appears or persists after a urethrovesical suspension procedure, warrants a complete urodynamic evaluation to detect the pattern of urethral obstruction. Indeed, a large post-void residual postoperatively can be secondary to poor bladder contractility, myogenic impairment from prolonged unrelieved obstruction, occult neurological disease or psychogenic disorders, or it can be induced pharmacologically (antidepressant medications, oxybutynin). Functional or organic urethral obstruction also can cause dysfunction postoperatively. Organic urethral obstruction is classified further by the anatomical level (bladder neck, proximal urethra, mid urethra and distal urethra) and by the histological level of obstruction (strictures and luminal deviations of the mucosa,

The entity of urethral obstruction after a MarshallMarchetti-Krantz must be recognized. Such a diagnosis requires radiographic and urodynamic documentations. Periurethral scarring and/or placement of a suspension suture in or closely adjacent to the urethra may result in urethral distortion with resultant luminal and/or extraluminal obstruction. Careful application of the modified technique described by Marchetti and associates 8 should help to prevent this urethral complication, although this could not be assessed in our series. More recent techniques, such as the transvaginal operation described, have emphasized the placement of supporting sutures as far lateral as possible from the periurethral area. Cure of stress incontinence has been achieved with comparable excellent results but with minimal occurrence of detrusor instability and absence of iatrogenic urethral obstruction. 12 Because conservative modalities, such as dilations, intermittent selfcatheterization and pharmacotherapy, have failed undeniably

520

ZIMMERN AND ASSOCIATES

in restoring a permanent normal voiding pattern, we suggest that a surgical alternative with low morbidity, such as this transvaginal approach, be contemplated. With this technique a definitive cure can be obtained in operable patients with preoperative urodynamic confirmation of outflow obstruction and preserved detrusor function. REFERENCES 1. Marshall, V. F., Marchetti, A. A. and Krantz, K. E.: The correction

of stress incontinence by simple vesicourethral suspension. Surg., Gynec. & Obst., 88: 509, 1949. 2. McDuffie, R. W., Jr., Litin, R. B. and Blundon, K. E.: Urethrovesical suspension (Marshall-Marchetti-Krantz). Experience with 204 cases. Amer. J. Surg., 141: 297, 1981. 3. Rost, A., Fiedler, U. and Fester, C.: Comparative analysis of the results of suspension-urethroplasty according to MarshallMarchetti-Krantz and of urethrovesicopexy with adhesive. Urol. Int., 34: 167, 1979. 4. Sarramon, J.P., Lhez, J.M., Courty, P. and Randua Nalimana, B.: Intervention de Marshall-Marchetti-Krantz au cours des incontinences a !'effort. Apropos de 100 cas. J. d'Urol., 87: 515, 1981.

5. Leach, G. E. and Raz, S.: Modified Pereyra bladder neck suspension

after previously failed anti-incontinence surgery. Surgical technique and results with long-term follow-up. Urology, 23: 359, 1984.

6. Hadley, H. R., Zimmern, P. E., Staskin, D. R. and Raz, S.: Transvaginal needle bladder neck suspension. Urol. Clin. N. Amer., 12: 291, 1985. 7. Leach, G. E., O'Donnell, P. and Raz, S.: Needle urethral-vesical suspension procedures. In: Female Urology. Edited by S. Raz. Philadelphia: W. B. Saunders Co., chapt. 18, pp. 276-292, 1983. 8. Marchetti, A. A., Marshall, V. F. and Shultis, L. D.: Simple vesicourethral suspension; a survey. Amer. J. Obst. Gynec., 74: 57, 1957.

9. McGuire, E. J. and Savastano, J. A.: Stress incontinence and detrusor instability/urge incontinence. Neurourol. Urodynam., 4: 313, 1985. 10. Tanagho, E. A.: The effect of hysterectomy and periurethral surgery on urethrovesical function. In: Gynecologic Urology and Urodynamics: Theory and Practice. Edited by D.R. Ostergard. Baltimore: The Williams & Wilkins Co., chapt. 29, p. 293, 1980. 11. Vanwelkenhuyzen, P., Edrich, M. and Delannoy, J.: La valeur de !'operation de Marshall-Marchetti dans le traitement de !'incontinence vesicale feminine. Acta Urol. Belgica, 52: 291, 1984. 12. Leach, G. E., Yip, C. M. and Donovan, B.: Mechanism of continence after modified Pereyra bladder neck suspension: prospective urodynamic study. Urology, 26: 328, 1987.