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Urethral obstruction after anti-incontinence surgery in women: Evaluation, methodology, and surgical results
ELSEVIER
URETHRAL OBSTRUCTION AFTER ANTI-INCONTINENCE SURGERY IN WOMEN: EVALUATION, METHODOLOGY, AND SURGICAL RESULTS PAUL
AUSTIN,
EVANGELOS MITCHELL
SPYROPOULOS, RICHARD HOFFMAN, AND JORGE
LOTENFOE, MOHAMED L. LOCKHART
HELAL,
ABSTRACT Objectives. To evaluate a group of women with voiding dysfunction and a low maximum flow rate (MFR) (less than or equal to 12 mUs) after surgery for stress urinary incontinence (SUI); to establish diagnostic parameters indicating obstruction in an attempt to determine treatment selection; and to evaluate preliminary surgical results. Methods. Eighteen women who underwent anti-incontinence surgery for SUI were diagnosed as having infravesical obstruction (IO). Thirteen women (group A [72%]) presented with clinically predominant symptoms of urgency, frequency, intermittency, and a variable vesical residual volume (RV), and five (group B [28%]) had as their most significant symptoms a high vesical RV and urinary tract infections that had been managed with intermittent catheterization (IC). The diagnosis of IO, suspected after clinical history, was established after physical examination and cystoscopic, cystographic and urodynamic investigations. Results. Bladder instability was demonstrated in 6 group A patients (46%) and 1 group B patient (20%) (P = NS). Mean MFRs were 8.07 and 7.2 mUs, respectively, in both groups (P = NS). Mean maximal voiding pressures (MVPs) were 20.23 and 5 cm H20, and mean RVs were 57.46 and 174 mL, respectively; both differences were statistically very significant (P ~0.0 1 and P co.00 1, respectively). High to normal MVPs occurred in 2 patients overall (1 1%). Bladder neck overcorrection, midurethral distortion, and postsurgical cystocele were demonstrated in both groups in 1 1 (85%), 0, and 2 (15%) patients in group A and 3 (60%), 2 (40%), and 3 (60%) patients in group B, respectively (P = NS). Patients in group A were treated surgically with cystourethrolysis and a repeated, less obstructive anti-incontinence operation. In group B 2 women (40%) had a similar surgical procedure; 1 (20%) underwent isolated urethrolysis; and 2 (40%) are currently maintained with IC. Conclusions. Among these 18 patients with voiding dysfunction after anti-incontinence surgery, a primary diagnosis of IO was established clinically. Only patients with a low MFR were selected for this study. Cystographic and endoscopic investigation as well as the presence of a postsurgical cystocele assisted in establishing the diagnosis. The success rate with urethrolysis and resuspension was 60% for the 13 women with predominantly urgency, frequency, and the highest MVPs (20.23 +- 9.67 cm Hz0 [group A]) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 -t 7.07 cm H20 [group B]). An added resuspension procedure is probably unnecessary in the latter group of patients and requires careful individual selection in the former group. UROLOGY 47: 890-894, 1996.
urgical management Sincontinence (SUI)
of female stress urinary is successful in 80% to
From the Division of Urology, Department of Surgery, and Department ofObstetrics and Gynecology, University ofSouth Florida Health Sciences Center, Tampa General Hospital; and H. Lee Moff;tt Cancer and Research Institute, Tampa, Florida Reprint requests: Jorge L. Lockhart, MD, Department of Surgery, University of South Florida, Harbourside Medical Tower, 4 Columbia Drive, Suite 730, Tampa, FL 33606 Submitted: November 27, 1995; accepted (with revisions): December
28, 19%
890
COPYRIGHT 1996 BY ELSEVIER SCIENCE ALLRIGHTSRESERVED
INC.
90% of patients.l Suture failure, bladder instability, inadequate surgical technique, and poor bladder contractility have been associated with poor results.2 Preoperative patient selection is essential, particularly among women presenting with simultaneous frequency, urgency, urge incontinence, or manifestations of voiding dysfunction. Five to seven percent of all retropubic and needle suspension procedures demonstrate incomplete vesical emptying.3 Although this event can be related to poor vesical contractility, in some situations it is 0090-4295/96/$15.00 PII SOO90-4295( 96) 00072-6
TABLE
I.
Symptomatology ofpersistent voiding anti-incontinence surgery Frequency/Urgency
Group A (n = 13) Group B (n = 5) P value Data presented
are number
13 (100%) 1 (20%)
AND METHODS
PATIENTS We retrospectively evaluated 18 women (mean age 61 years; range 22 to 78) for persistent voiding dysfunction after anti-incontinence surgery. No patient presented in a polyuric state or with neurogenic disease. Their symptoms persisted for at least 6 months after the surgical procedure. The number of previous surgical procedures ranged between 1 and 11, with an average of 2.7 per patient. No patient had presented with voiding dysfunction before the previous anti-incontinence procedure, nor were hesitancy, urgency, and urge incontinence significant symptoms in any patient before surgery. After surgery, all patients underwent a variety of nonoperative treatment modalities that included biofeedback, urethral dilation, and pharmacologic therapy in different combinations, without improvement. Among all patients, preoperative SUI manifestations had diminished or ceased. Although there was overlapping symptomatology, patients were classified into two groups according to degree of vesical residual volume (RV) and intermittent catheterization (IC) required (Table I). GROUP A Thirteen patients presented predominantly with bladder irritability manifestations, including frequency/urgency ( 13 patients [ 100% I ) , hesitancy ( 12 patients [ 92% I ) , and vesical RV that ranged from 0 to 130 mL (mean 57 mL) . The last operation performed had been a needle suspension in 11 patients and a Marshall-Marchetti operation in 2.
GROUP I3 Five patients had manifestations of urinary retention required IC for vesical emptying. Two patients (40%) UROLOGY
47 (6)) 1996
after
Symptom Hesitancy
Retention
12 (92.3%) 3 (60%) NS
0 (0%) 2 (40%) NS
(%) of patients.
caused by infravesical obstruction (IO). With the popularization of a variety of surgical techniques for the management of female SUI, the incidence of IO has increased in our referral pattern. Pressure-flow changes indicating obstruction in male patients (high voiding pressure, low flow) are not commonly found in women.4 A high percentage of women presenting with IO after antiincontinence surgery demonstrate an impaired flow without an elevation in micturition pressure.4 We studied 18 women with persistent voiding dysfunction associated with a poor maximum flow rate (MFR) and suspected IO after anti-incontinence surgery for SUI. The present study sought to establish significant IO diagnostic parameters that would allow rational classification and selection of patients for further surgical therapy. MATERIAL
dysfunction
and had
complete urinary retention. Residual volume was greater than or equal to 150 mL in all five patients (Table II). The last operation performed had been a needle suspension in 3 patients and a sling procedure in 1. The final patient had undergone surgery for a failed artificial urinary sphincter.
URODYNAMIC, CYSTOGRAPHIC,ANDCYSTOSCOPIC ~~vVE~T~GATI~N~ All patients underwent full urodynamic, cystographic, and cystoscopic investigation. Urodynamic evaluation consisted of measurement of initial uroflowmetry, followed by supine and upright cystometry utilizing a trilumen Bard catheter. Provocative maneuvers were utilized, including asking the patient to cough and Valsalva. Pressure-flow recording and postvoiding vesical RVs were obtained. Simultaneous monitoring of intravesical, rectal, and subtracted bladder pressures was performed. Because IO can be associated with a variety of MFRs, only patients presenting with a low MFR (less than or equal to 12 mUs) were selected for the present study.4 All patients underwent lateral cystography and cystoscopy in an attempt to evaluate bladder neck position and funneling, as well as proximal and distal urethral opening during voiding. The presence of a highly elevated bladder neck behind the pubic bone or absent funneling or descent during voiding attempts was indicative of obstruction. Urethral tortuosity with inappropriate opening of the distal urethra and proximal dilation were considered indicative of midurethral obstruction. Bladder base descent was assessed to determine whether a postsurgical cystocele was present. Similar anatomic changes were carefully sought cystoscopically. Statistical comparison between both groups was performed utilizing the t test (unpaired t test) and chi-square test (Fisher’s exact test).
RESULTS
GROUP A Among the 13 patients in group A (predominantly bladder irritability manifestations), detrusor filling pressure recording demonstrated bladder stability in 7 patients (53.8%) and bladder instability in 6 (46.2%). The MVP ranged between 10 and 36 cm Hz0 (mean 20.2) ; maximum cystometric capacity (MCC) between 175 and 520 mL (mean 302) ; MFR between 6 and 12 mUs (mean 8.07). Only 2 patients were shown to present with the pattern of a high to normal MVP (greater than or equal to 35 cm HzO) and a low MFR. Cystographic and cystoscopic evaluation demonstrated a bladder neck overcorrection (BNO) in 11 patients (85%), and 2 (15%) presented with a cystocele (Table II). All 13 patients 891
TABLE
II. MCC (mL1
Croup A (n = 13) Group B (n = 5) P value
302 2 92.7 288 -+ 77.2 NS
Urodynamic
and clinical
Urodynamic MVP (cm H&l 20.23
? 9.67
5.00 t 7.07
parameters
voiding
Parameters MFR (mW
RV (ml,)
Instability
8.07 2 2.8
57.46 5 55.54
6 (46.2%)
174 -+ 33
1 (20%) NS
7.2 2 3.37 NS
KEY: MCC = maximum cystometric capacity; MVP = maximum voiding (according to International Continence Society standardization criteria); Data presented are mean value 2 SD or number (%I ofpatients.
dysfunction
CystologicKystoscopic
Parameters
BNO
MUD
Cystocele
11 (85%] 3 (60%) NS
0 (0%) 2 (40%) NS
(152961 3 (60%) NS
pressure; MFR = maximumflow rate; RV = residual urinevolume; Instability BNO = bladder neck overcorrection; MUD = midurethral distortion.
underwent urethrolysis and resuspension utilizing a sling. Twelve patients (92.3%) are continent after surgery; however, only 7 are satisfied with the surgical result. Six patients (46%) are dissatisfied because of persistent urgency and frequency (4 patients) , recurrent stress incontinence ( 1 patient), and ventral hernia development (1 patient). Among the 4 patients with persistent urgency and frequency, 3 (75%) had presented with preoperative bladder instability that persisted postoperatively. Stress incontinence was cured with a periurethral Polytef injection in 1 patient, and bladder instability improved in another after augmentation cystoplasty and IC.
GROUPB Among the 5 patients in group B (predominantly with inability to urinate), detrusor filling pressure recording showed bladder stability in 4 (80%) and detrusor instability in 1 (20%). The MVP ranged between 0 and 15 cm Hz0 (mean 5)) MCC between 220 and 420 mL (mean 288)) and MFR between 3 and 11 mUs (mean 7.2). Two patients (40%) had midurethral distortion (MUD), and BNO was present in 3 (60%). Both abnormalities coexisted in 1 patient, and a postsurgical cystocele was demonstrated in 3 (60%) (Table II). Differences between both groups were statistically very significant for MVP and RV, but were not statistically significant for BNO, MUD, and the presence of a cystocele (Table II). Three patients (60%) in group B underwent urethrolysis (in 2 patients a sling was added to the procedure). Two patients (40%) have refused more surgery and are maintained with IC. The patient undergoing isolated urethrolysis still has urinary retention and is presently scheduled for repeat urethrolysis. Of the 2 patients undergoing urethrolysis and a sling procedure, 1 urinates and is satisfied; the other could not urinate and subsequently had a failed second urethrolysis. Both patients had presented with a stable detrusor preoperatively. 892
of persistent
= detncsor
instability
COMMENT Suture failure, bladder instability, inadequate surgical technique, and poor bladder contractility have been associated with suboptimal surgical resUlts.2.5 With the recent popularization of surgical techniques for the management of different types of female SUI, the number of patients presenting with IO in our practice has increased. In a previous report, 6 we found that the most common abnormal conditions encountered after failed anti-incontinence surgery included the development of high RV, persistent SUI, and bladder instability. At present, it is believed that some women who develop elevated RV or refractory urgency and frequency after surgery also develop IO.4,7 It is not uncommon for women to occasionally present with voiding difficulties and require temporary IC after this type of surgery. However, with the resolution of edema and pain, most subjects regain normal voiding function. Webster et ~1.~ established that the presence of postoperative obstruction is difficult to assess urodynamically. They also established that an impaired flow represented the most common abnormality found with these studies. In an attempt to determine diagnostic modalities indicating IO and to establish further therapy, we selected women with persistent voiding dysfunction and a low postoperative MFR. In two previous series,4%7 patients with IO presented with urinary retention or symptoms of vesical irritability. In our group of patients we found both abnormalities, but the presence of refractory urgency and frequency predominated. Interestingly, bladder instability was demonstrated in only 46% of patients with clinical urgency and urge incontinence, similar to the report of Webster et ~1.~ We found high to normal voiding pressures associated with low flow in only 2 patients. From previous reports and our own data, it is clear that this voiding pattern is infrequently documented in women.4 Massey and Abrams* have suggested that the presence of an MVP greater than or equal to 50 cm Hz0 is indicative of obstruction in women. UROLOGY
47 (6), 1996
However, we have not encountered such an abnormality among our patients. It is possible that a high MVP could be encountered more often in the immediate postoperative period. In women with a normal MFR, it would be difficult to demonstrate IO unless a concomitantly elevated MVP could be shown. Among patients with a normal MFR, urodynamic studies would be of little assistance in diagnosing IO. From the therapeutic point of view, the presence or absence of bladder instability is of no significance. These patients do not respond to anticholinergic medication or other conservative therapies. In both groups of patients, treatment should be focused on relieving or bypassing outlet resistance with a new surgical procedure or an IC program. Cystographic and cystoscopic investigation are essential in the demonstration of BNO. This is primarily a subjective determination that was made in 85% and 60% of both groups, respectively. Similarly, the presence of MUD, as demonstrated by angulation of the middle or distal third of the urethra with proximal dilation, is an indication of improper suture placement by the surgeon, often causing voiding impairment. In the latter situation, removal of the sutures is essential to allow proper urethral opening during micturition. The presence of a postsurgical cystocele represents an anatomic condition commonly associated with abnormal voiding. In our experience, when a postsurgical cystocele coexists with IO symptomatology, surgical correction is required unless the patient accepts an IC program. Women presenting with severe urgency and urge incontinence require relief of outlet resistance when BNO or MUD, or both, exist. Both anatomic abnormalities in the same group of patients have not responded to urethral dilation with or without IC; management requires lysis not only of the proximal urethra and bladder neck, but also the anterior bladder wall from the posterior aspect of the pubis. Leach and Razg reported the results of the first urethrolysis for the management of stress incontinence associated with a fibrotic and noncompliant urethra. After this procedure, they performed a modified Pereyra bladder neck suspension, achieving a 94% success rate (minimum follow-up 2 years > . Unfortunately, these results have not been reproduced by other surgeons. Utilizing a similar technique, Nitti and Razl’ reported an 80% success rate among 33 patients who were considered to have preoperative IO. Foster and McGuirell reported a 65% success rate among 48 patients treated with transvaginal urethrolysis without an added suspension. Webster et a1.4 recommend retropubic urethrolysis dissection followed by obUROLOGY
47 (6). 1996
turator shelf suspension.’ In our experience, a transvaginal approach allows proper mobilization in most cases. Only 1 woman presented with an extremely dense retropubic fibrotic mass (she had undergone 11 failed anti-incontinence procedures) and required a combined transvaginal and suprapubic cystourethrolysis. McGuire and colleagues7,11 have proposed vaginal urethrolysis without a new suspension in a number of such cases. We believe that this is probably a safe alternative for our group B patients who have poor vesical contractility in association with their obstructive condition. However, in our group A patients with urgency and demonstrable voiding pressure, we were confident in treatment with isolated urethrolysis. For that reason, we added a nonobstructive sling to the management of these patients. One patient developed recurrent SUI despite the added sling. Perhaps if other patients in this group had not undergone a sling procedure, we would have observed a higher incidence of SUI. Among 5 patients with urinary retention, 2 (40%) have preferred maintenance with IC; among the 3 patients who underwent surgery, 2 (66%) still cannot urinate despite urethrolysis. The results of urethrolysis in our patients with existing preoperative voiding function were similar to those of Foster and McGuire.” Among the patients with urinary retention, the added antiincontinence procedure is probably unnecessary because some patients still will not urinate after an isolated urethrolysis. In summary, we evaluated 18 women with failed anti-incontinence surgery for SUI who presented with voiding dysfunction and a low MFR. A multimodal approach with clinical, cystoscopic, and urodynamic investigation is essential to differentiate those patients who might require a different surgical treatment. We selected women with demonstrable vesical voiding pressure for cystourethrolysis and resuspension. Bladder instability was associated with 75% of treatment failures with persistent urgency and frequency. Added resuspension in this group might not be necessary in all patients. Women who primarily had a high RV with poor or absent vesical contractility were not initially encouraged to undergo further surgery. Among 3 patients who underwent operation, 1 (33% > has regained voiding function. Resuspension after urethrolysis in this group of patients is probably unnecessary. Long-term follow-up in both groups will determine the feasibility of this assessment. REFERENCES 1. Pow-Sang JM, Lockhart JL, Suarez A, Lansman H, and Politano VA: Female urinary incontinence: preoperative se893
lection, surgical complications and results. J Urol 136: 831833, 1986. 2. Raz S, Maggio, AJ Jr, and Kaufman JJ: Why MarshallMarchetti operation works. or does not. Urology 14: 154159, 1979. 3. Spencer JR, and O’Connor VJ Jr: Comparison of procedures for stress urinary incontinence. AUA Update Series, vol. VI, lesson 28, 1987. 4. Webster GD, and Kreder KJ: Voiding dysfunction following cystourethropexy: its evaluation and management. J Ural 144: 670-673, 1990. 5. Kreder KJ: Complications associated with female incontinence surgery. AUA Update Series, vol. XII, lesson 28, 1993. 6. Lockhart JL, Tirado A, Morillo G, and Politano VA: Vesicourethral dysfunction following cystourethropexy. J Urol 128: 943-945,1982.
894
7. McGuire EJ, Letson W, and Wang S: Transvaginal urethrolysis after obstructive urethral suspension procedures. J Ural 142: 1037-1039, 1989. 8. Massey JA, and Abrams PH: Obstructed voiding in the female. Br J Urol 61: 36-39, 1988. 9. Leach GE, and Raz S: Modified Pereyra bladder neck suspension after previously failed anti-incontinence surgery. Urology 23: 359-362, 1984. 10. Nitti VW, and Raz S: Obstruction following anti-incontinence procedures: diagnosis and treatment with transvaginal urethrolysis. J Urol 152: 93-98, 1994. 11. Foster HE, and McGuire EJ: Management of urethral obstruction with transvaginal urethrolysis. J Urol 150: 14481451,1993. 12. Abrams PH, Blaivas JG, Stanton SL, Anderson JT: Standardization of terminology of lower urinary tract function. Neurourol Urodyn 7: 403-427, 1988.
UROLOGY
47 (6), 1996
URETHRAL OBSTRUCTION AFTER ANTI-INCONTINENCE SURGERY IN WOMEN: EVALUATION, METHODOLOGY, AND SURGICAL RESULTS PAUL
AUSTIN,
EVANGELOS MITCHELL
SPYROPOULOS, RICHARD HOFFMAN, AND JORGE
LOTENFOE, MOHAMED L. LOCKHART
HELAL,
ABSTRACT Objectives. To evaluate a group of women with voiding dysfunction and a low maximum flow rate (MFR) (less than or equal to 12 mUs) after surgery for stress urinary incontinence (SUI); to establish diagnostic parameters indicating obstruction in an attempt to determine treatment selection; and to evaluate preliminary surgical results. Methods. Eighteen women who underwent anti-incontinence surgery for SUI were diagnosed as having infravesical obstruction (IO). Thirteen women (group A [72%]) presented with clinically predominant symptoms of urgency, frequency, intermittency, and a variable vesical residual volume (RV), and five (group B [28%]) had as their most significant symptoms a high vesical RV and urinary tract infections that had been managed with intermittent catheterization (IC). The diagnosis of IO, suspected after clinical history, was established after physical examination and cystoscopic, cystographic and urodynamic investigations. Results. Bladder instability was demonstrated in 6 group A patients (46%) and 1 group B patient (20%) (P = NS). Mean MFRs were 8.07 and 7.2 mUs, respectively, in both groups (P = NS). Mean maximal voiding pressures (MVPs) were 20.23 and 5 cm H20, and mean RVs were 57.46 and 174 mL, respectively; both differences were statistically very significant (P ~0.0 1 and P co.00 1, respectively). High to normal MVPs occurred in 2 patients overall (1 1%). Bladder neck overcorrection, midurethral distortion, and postsurgical cystocele were demonstrated in both groups in 1 1 (85%), 0, and 2 (15%) patients in group A and 3 (60%), 2 (40%), and 3 (60%) patients in group B, respectively (P = NS). Patients in group A were treated surgically with cystourethrolysis and a repeated, less obstructive anti-incontinence operation. In group B 2 women (40%) had a similar surgical procedure; 1 (20%) underwent isolated urethrolysis; and 2 (40%) are currently maintained with IC. Conclusions. Among these 18 patients with voiding dysfunction after anti-incontinence surgery, a primary diagnosis of IO was established clinically. Only patients with a low MFR were selected for this study. Cystographic and endoscopic investigation as well as the presence of a postsurgical cystocele assisted in establishing the diagnosis. The success rate with urethrolysis and resuspension was 60% for the 13 women with predominantly urgency, frequency, and the highest MVPs (20.23 +- 9.67 cm Hz0 [group A]) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 -t 7.07 cm H20 [group B]). An added resuspension procedure is probably unnecessary in the latter group of patients and requires careful individual selection in the former group. UROLOGY 47: 890-894, 1996.
urgical management Sincontinence (SUI)
of female stress urinary is successful in 80% to
From the Division of Urology, Department of Surgery, and Department ofObstetrics and Gynecology, University ofSouth Florida Health Sciences Center, Tampa General Hospital; and H. Lee Moff;tt Cancer and Research Institute, Tampa, Florida Reprint requests: Jorge L. Lockhart, MD, Department of Surgery, University of South Florida, Harbourside Medical Tower, 4 Columbia Drive, Suite 730, Tampa, FL 33606 Submitted: November 27, 1995; accepted (with revisions): December
28, 19%
890
COPYRIGHT 1996 BY ELSEVIER SCIENCE ALLRIGHTSRESERVED
INC.
90% of patients.l Suture failure, bladder instability, inadequate surgical technique, and poor bladder contractility have been associated with poor results.2 Preoperative patient selection is essential, particularly among women presenting with simultaneous frequency, urgency, urge incontinence, or manifestations of voiding dysfunction. Five to seven percent of all retropubic and needle suspension procedures demonstrate incomplete vesical emptying.3 Although this event can be related to poor vesical contractility, in some situations it is 0090-4295/96/$15.00 PII SOO90-4295( 96) 00072-6
TABLE
I.
Symptomatology ofpersistent voiding anti-incontinence surgery Frequency/Urgency
Group A (n = 13) Group B (n = 5) P value Data presented
are number
13 (100%) 1 (20%)
AND METHODS
PATIENTS We retrospectively evaluated 18 women (mean age 61 years; range 22 to 78) for persistent voiding dysfunction after anti-incontinence surgery. No patient presented in a polyuric state or with neurogenic disease. Their symptoms persisted for at least 6 months after the surgical procedure. The number of previous surgical procedures ranged between 1 and 11, with an average of 2.7 per patient. No patient had presented with voiding dysfunction before the previous anti-incontinence procedure, nor were hesitancy, urgency, and urge incontinence significant symptoms in any patient before surgery. After surgery, all patients underwent a variety of nonoperative treatment modalities that included biofeedback, urethral dilation, and pharmacologic therapy in different combinations, without improvement. Among all patients, preoperative SUI manifestations had diminished or ceased. Although there was overlapping symptomatology, patients were classified into two groups according to degree of vesical residual volume (RV) and intermittent catheterization (IC) required (Table I). GROUP A Thirteen patients presented predominantly with bladder irritability manifestations, including frequency/urgency ( 13 patients [ 100% I ) , hesitancy ( 12 patients [ 92% I ) , and vesical RV that ranged from 0 to 130 mL (mean 57 mL) . The last operation performed had been a needle suspension in 11 patients and a Marshall-Marchetti operation in 2.
GROUP I3 Five patients had manifestations of urinary retention required IC for vesical emptying. Two patients (40%) UROLOGY
47 (6)) 1996
after
Symptom Hesitancy
Retention
12 (92.3%) 3 (60%) NS
0 (0%) 2 (40%) NS
(%) of patients.
caused by infravesical obstruction (IO). With the popularization of a variety of surgical techniques for the management of female SUI, the incidence of IO has increased in our referral pattern. Pressure-flow changes indicating obstruction in male patients (high voiding pressure, low flow) are not commonly found in women.4 A high percentage of women presenting with IO after antiincontinence surgery demonstrate an impaired flow without an elevation in micturition pressure.4 We studied 18 women with persistent voiding dysfunction associated with a poor maximum flow rate (MFR) and suspected IO after anti-incontinence surgery for SUI. The present study sought to establish significant IO diagnostic parameters that would allow rational classification and selection of patients for further surgical therapy. MATERIAL
dysfunction
and had
complete urinary retention. Residual volume was greater than or equal to 150 mL in all five patients (Table II). The last operation performed had been a needle suspension in 3 patients and a sling procedure in 1. The final patient had undergone surgery for a failed artificial urinary sphincter.
URODYNAMIC, CYSTOGRAPHIC,ANDCYSTOSCOPIC ~~vVE~T~GATI~N~ All patients underwent full urodynamic, cystographic, and cystoscopic investigation. Urodynamic evaluation consisted of measurement of initial uroflowmetry, followed by supine and upright cystometry utilizing a trilumen Bard catheter. Provocative maneuvers were utilized, including asking the patient to cough and Valsalva. Pressure-flow recording and postvoiding vesical RVs were obtained. Simultaneous monitoring of intravesical, rectal, and subtracted bladder pressures was performed. Because IO can be associated with a variety of MFRs, only patients presenting with a low MFR (less than or equal to 12 mUs) were selected for the present study.4 All patients underwent lateral cystography and cystoscopy in an attempt to evaluate bladder neck position and funneling, as well as proximal and distal urethral opening during voiding. The presence of a highly elevated bladder neck behind the pubic bone or absent funneling or descent during voiding attempts was indicative of obstruction. Urethral tortuosity with inappropriate opening of the distal urethra and proximal dilation were considered indicative of midurethral obstruction. Bladder base descent was assessed to determine whether a postsurgical cystocele was present. Similar anatomic changes were carefully sought cystoscopically. Statistical comparison between both groups was performed utilizing the t test (unpaired t test) and chi-square test (Fisher’s exact test).
RESULTS
GROUP A Among the 13 patients in group A (predominantly bladder irritability manifestations), detrusor filling pressure recording demonstrated bladder stability in 7 patients (53.8%) and bladder instability in 6 (46.2%). The MVP ranged between 10 and 36 cm Hz0 (mean 20.2) ; maximum cystometric capacity (MCC) between 175 and 520 mL (mean 302) ; MFR between 6 and 12 mUs (mean 8.07). Only 2 patients were shown to present with the pattern of a high to normal MVP (greater than or equal to 35 cm HzO) and a low MFR. Cystographic and cystoscopic evaluation demonstrated a bladder neck overcorrection (BNO) in 11 patients (85%), and 2 (15%) presented with a cystocele (Table II). All 13 patients 891
TABLE
II. MCC (mL1
Croup A (n = 13) Group B (n = 5) P value
302 2 92.7 288 -+ 77.2 NS
Urodynamic
and clinical
Urodynamic MVP (cm H&l 20.23
? 9.67
5.00 t 7.07
parameters
voiding
Parameters MFR (mW
RV (ml,)
Instability
8.07 2 2.8
57.46 5 55.54
6 (46.2%)
174 -+ 33
1 (20%) NS
7.2 2 3.37 NS
KEY: MCC = maximum cystometric capacity; MVP = maximum voiding (according to International Continence Society standardization criteria); Data presented are mean value 2 SD or number (%I ofpatients.
dysfunction
CystologicKystoscopic
Parameters
BNO
MUD
Cystocele
11 (85%] 3 (60%) NS
0 (0%) 2 (40%) NS
(152961 3 (60%) NS
pressure; MFR = maximumflow rate; RV = residual urinevolume; Instability BNO = bladder neck overcorrection; MUD = midurethral distortion.
underwent urethrolysis and resuspension utilizing a sling. Twelve patients (92.3%) are continent after surgery; however, only 7 are satisfied with the surgical result. Six patients (46%) are dissatisfied because of persistent urgency and frequency (4 patients) , recurrent stress incontinence ( 1 patient), and ventral hernia development (1 patient). Among the 4 patients with persistent urgency and frequency, 3 (75%) had presented with preoperative bladder instability that persisted postoperatively. Stress incontinence was cured with a periurethral Polytef injection in 1 patient, and bladder instability improved in another after augmentation cystoplasty and IC.
GROUPB Among the 5 patients in group B (predominantly with inability to urinate), detrusor filling pressure recording showed bladder stability in 4 (80%) and detrusor instability in 1 (20%). The MVP ranged between 0 and 15 cm Hz0 (mean 5)) MCC between 220 and 420 mL (mean 288)) and MFR between 3 and 11 mUs (mean 7.2). Two patients (40%) had midurethral distortion (MUD), and BNO was present in 3 (60%). Both abnormalities coexisted in 1 patient, and a postsurgical cystocele was demonstrated in 3 (60%) (Table II). Differences between both groups were statistically very significant for MVP and RV, but were not statistically significant for BNO, MUD, and the presence of a cystocele (Table II). Three patients (60%) in group B underwent urethrolysis (in 2 patients a sling was added to the procedure). Two patients (40%) have refused more surgery and are maintained with IC. The patient undergoing isolated urethrolysis still has urinary retention and is presently scheduled for repeat urethrolysis. Of the 2 patients undergoing urethrolysis and a sling procedure, 1 urinates and is satisfied; the other could not urinate and subsequently had a failed second urethrolysis. Both patients had presented with a stable detrusor preoperatively. 892
of persistent
= detncsor
instability
COMMENT Suture failure, bladder instability, inadequate surgical technique, and poor bladder contractility have been associated with suboptimal surgical resUlts.2.5 With the recent popularization of surgical techniques for the management of different types of female SUI, the number of patients presenting with IO in our practice has increased. In a previous report, 6 we found that the most common abnormal conditions encountered after failed anti-incontinence surgery included the development of high RV, persistent SUI, and bladder instability. At present, it is believed that some women who develop elevated RV or refractory urgency and frequency after surgery also develop IO.4,7 It is not uncommon for women to occasionally present with voiding difficulties and require temporary IC after this type of surgery. However, with the resolution of edema and pain, most subjects regain normal voiding function. Webster et ~1.~ established that the presence of postoperative obstruction is difficult to assess urodynamically. They also established that an impaired flow represented the most common abnormality found with these studies. In an attempt to determine diagnostic modalities indicating IO and to establish further therapy, we selected women with persistent voiding dysfunction and a low postoperative MFR. In two previous series,4%7 patients with IO presented with urinary retention or symptoms of vesical irritability. In our group of patients we found both abnormalities, but the presence of refractory urgency and frequency predominated. Interestingly, bladder instability was demonstrated in only 46% of patients with clinical urgency and urge incontinence, similar to the report of Webster et ~1.~ We found high to normal voiding pressures associated with low flow in only 2 patients. From previous reports and our own data, it is clear that this voiding pattern is infrequently documented in women.4 Massey and Abrams* have suggested that the presence of an MVP greater than or equal to 50 cm Hz0 is indicative of obstruction in women. UROLOGY
47 (6), 1996
However, we have not encountered such an abnormality among our patients. It is possible that a high MVP could be encountered more often in the immediate postoperative period. In women with a normal MFR, it would be difficult to demonstrate IO unless a concomitantly elevated MVP could be shown. Among patients with a normal MFR, urodynamic studies would be of little assistance in diagnosing IO. From the therapeutic point of view, the presence or absence of bladder instability is of no significance. These patients do not respond to anticholinergic medication or other conservative therapies. In both groups of patients, treatment should be focused on relieving or bypassing outlet resistance with a new surgical procedure or an IC program. Cystographic and cystoscopic investigation are essential in the demonstration of BNO. This is primarily a subjective determination that was made in 85% and 60% of both groups, respectively. Similarly, the presence of MUD, as demonstrated by angulation of the middle or distal third of the urethra with proximal dilation, is an indication of improper suture placement by the surgeon, often causing voiding impairment. In the latter situation, removal of the sutures is essential to allow proper urethral opening during micturition. The presence of a postsurgical cystocele represents an anatomic condition commonly associated with abnormal voiding. In our experience, when a postsurgical cystocele coexists with IO symptomatology, surgical correction is required unless the patient accepts an IC program. Women presenting with severe urgency and urge incontinence require relief of outlet resistance when BNO or MUD, or both, exist. Both anatomic abnormalities in the same group of patients have not responded to urethral dilation with or without IC; management requires lysis not only of the proximal urethra and bladder neck, but also the anterior bladder wall from the posterior aspect of the pubis. Leach and Razg reported the results of the first urethrolysis for the management of stress incontinence associated with a fibrotic and noncompliant urethra. After this procedure, they performed a modified Pereyra bladder neck suspension, achieving a 94% success rate (minimum follow-up 2 years > . Unfortunately, these results have not been reproduced by other surgeons. Utilizing a similar technique, Nitti and Razl’ reported an 80% success rate among 33 patients who were considered to have preoperative IO. Foster and McGuirell reported a 65% success rate among 48 patients treated with transvaginal urethrolysis without an added suspension. Webster et a1.4 recommend retropubic urethrolysis dissection followed by obUROLOGY
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turator shelf suspension.’ In our experience, a transvaginal approach allows proper mobilization in most cases. Only 1 woman presented with an extremely dense retropubic fibrotic mass (she had undergone 11 failed anti-incontinence procedures) and required a combined transvaginal and suprapubic cystourethrolysis. McGuire and colleagues7,11 have proposed vaginal urethrolysis without a new suspension in a number of such cases. We believe that this is probably a safe alternative for our group B patients who have poor vesical contractility in association with their obstructive condition. However, in our group A patients with urgency and demonstrable voiding pressure, we were confident in treatment with isolated urethrolysis. For that reason, we added a nonobstructive sling to the management of these patients. One patient developed recurrent SUI despite the added sling. Perhaps if other patients in this group had not undergone a sling procedure, we would have observed a higher incidence of SUI. Among 5 patients with urinary retention, 2 (40%) have preferred maintenance with IC; among the 3 patients who underwent surgery, 2 (66%) still cannot urinate despite urethrolysis. The results of urethrolysis in our patients with existing preoperative voiding function were similar to those of Foster and McGuire.” Among the patients with urinary retention, the added antiincontinence procedure is probably unnecessary because some patients still will not urinate after an isolated urethrolysis. In summary, we evaluated 18 women with failed anti-incontinence surgery for SUI who presented with voiding dysfunction and a low MFR. A multimodal approach with clinical, cystoscopic, and urodynamic investigation is essential to differentiate those patients who might require a different surgical treatment. We selected women with demonstrable vesical voiding pressure for cystourethrolysis and resuspension. Bladder instability was associated with 75% of treatment failures with persistent urgency and frequency. Added resuspension in this group might not be necessary in all patients. Women who primarily had a high RV with poor or absent vesical contractility were not initially encouraged to undergo further surgery. Among 3 patients who underwent operation, 1 (33% > has regained voiding function. Resuspension after urethrolysis in this group of patients is probably unnecessary. Long-term follow-up in both groups will determine the feasibility of this assessment. REFERENCES 1. Pow-Sang JM, Lockhart JL, Suarez A, Lansman H, and Politano VA: Female urinary incontinence: preoperative se893
lection, surgical complications and results. J Urol 136: 831833, 1986. 2. Raz S, Maggio, AJ Jr, and Kaufman JJ: Why MarshallMarchetti operation works. or does not. Urology 14: 154159, 1979. 3. Spencer JR, and O’Connor VJ Jr: Comparison of procedures for stress urinary incontinence. AUA Update Series, vol. VI, lesson 28, 1987. 4. Webster GD, and Kreder KJ: Voiding dysfunction following cystourethropexy: its evaluation and management. J Ural 144: 670-673, 1990. 5. Kreder KJ: Complications associated with female incontinence surgery. AUA Update Series, vol. XII, lesson 28, 1993. 6. Lockhart JL, Tirado A, Morillo G, and Politano VA: Vesicourethral dysfunction following cystourethropexy. J Urol 128: 943-945,1982.
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7. McGuire EJ, Letson W, and Wang S: Transvaginal urethrolysis after obstructive urethral suspension procedures. J Ural 142: 1037-1039, 1989. 8. Massey JA, and Abrams PH: Obstructed voiding in the female. Br J Urol 61: 36-39, 1988. 9. Leach GE, and Raz S: Modified Pereyra bladder neck suspension after previously failed anti-incontinence surgery. Urology 23: 359-362, 1984. 10. Nitti VW, and Raz S: Obstruction following anti-incontinence procedures: diagnosis and treatment with transvaginal urethrolysis. J Urol 152: 93-98, 1994. 11. Foster HE, and McGuire EJ: Management of urethral obstruction with transvaginal urethrolysis. J Urol 150: 14481451,1993. 12. Abrams PH, Blaivas JG, Stanton SL, Anderson JT: Standardization of terminology of lower urinary tract function. Neurourol Urodyn 7: 403-427, 1988.
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