Female obstruction after incontinence surgery may present different urodynamic patterns

Continence Is Not Affected after Sling Revision with Transvaginal Tape Elongation for Post-Sling Voiding Dysfunction

Voiding dysfunction (VD) after sling operation is not uncommon. Sling revisions by incision/excision are usually effective; however, they may result in recurrent stress urinary incontinence (SUI). We aimed to evaluate continence status after an innovative sling revision procedure that preserves the integrity of the sling. Patients who underwent either a single-incision (AJUST) or a trans-obturator (TVT-O) mid-urethral sling were studied. Transvaginal tape elongation (i.e., sling midline incision and mesh interposition) was performed on patients with post-sling VD. Factors that may affect recurrent SUI were investigated by statistical analyses. Of 119 patients, 90 (75.6%) (45 AJUST and 45 TVT-O) were available for long-term (median 9; 8-10 years) follow-up. A significantly higher rate (17.2% vs. 3.3%, p = 0.014) of VD was noted after AJUST (N = 10) than after TVT-O (N = 2). After sling revision, four (33%) of the 12 cases reported recurrent SUI, which was not significantly different (p = 1.000) from the rate (37%, 29/78) of patients who did not undergo sling revision. Further statistical analyses revealed no significant predisposing factors affecting the recurrence of SUI. Surgical continence did not seem to be affected by having had sling revision with transvaginal tape elongation for post-sling VD.

Retropubic tape surgery for stress urinary incontinence: can women be cured without voiding dysfunction?

PURPOSE

Retropubic tension free vaginal tape (RP-TVT) has become the gold standard for surgical management of female stress urinary incontinence but is associated with voiding dysfunction (VD). We developed for more than 10 years a reproductible and totally tension free tape procedure. Our goal is to determine efficiency of this technique compared to the incidence of VD.

METHODS

We retrospectively reviewed patients who underwent RP-TVT in our center between 2011 and 2019. Subjective cure, VD (determined as maximum urinary flow rate (Qmax) < 15 mL/s or post void residual (PVR) volume > 150 mL, or tape's section or resection requirement for underactive bladder (UB) with significant PVR) was assessed at 1 year. The main objective was the evaluation of subjective cure and VD at 1 year.

RESULTS

On the 319 patients reviewed, 93% of the patients were dry and 10.9% presented VD at one year. UB (OR = 5.01 [1.55-16.44], p = 0.008), preoperative Qmax < 15 mL/s (OR = 0.89 [0.84-0.95], p = 0.001) and previous incontinence surgery (OR = 4.20 [1.54-11.46], p = 0.005) were associated with VD. Acute urinary retention concerned 4.7% of the population and all were resolved after 6 weeks postoperatively. We reported 0.3% of de novo urgency and patients without VD showed a significant decrease of their voiding time at 1 year.

CONCLUSION

The placement of RP-TVT without intraoperative tightening seems to be a safe technique ensuring a high cure rate and low occurrences of bladder outlet obstruction.

Assessment and Management of Urinary Dysfunction in 187 Patients with Parkinson's Disease

BACKGROUND

Urinary dysfunction is common in Parkinson's disease (PD) patients and management options are limited.

OBJECTIVE

This study aimed to explore the management of urinary dysfunction by researching the special needs of PD patients.

METHODS

PD patients with urinary dysfunction who underwent urodynamic testing were recruited from a single center from October 2013 to February 2019. The urinary symptoms, International Prostate Symptom Score and Hoehn-Yahr scale were evaluated. Management was made at the urologists' discretion with follow-up after three weeks. Urinary symptoms, urodynamics and the management of urinary dysfunction were analyzed.

RESULTS

A total of 187 patients with a median age of 66.2 and Hoehn-Yahr scale soccer of 2 were enrolled. Irritative symptoms were more common than obstructive symptoms, while obstructive symptoms were more common in male than female patients, except for incomplete voiding. There were 51% cases of detrusor overactivity, followed by 33% with bladder outlet obstruction, 13% had normal function, 12% had detrusor underactivity, 9% had stress incontinence, 7% had increased bladder sensation and 4% had an acontractile bladder. Tolterodine and tamsulosin were the most common therapeutic agents, respectively prescribed to 38.5% and 27.3% of the patients. Other treatments included catheterization, botulinum toxin A bladder wall injection, transurethral resection of the prostate and urethral dilatation. Urinary symptoms were improved significantly in 74.5% of the patients (p < 0.001), including 27 patients treated with tamsulosin only and 54 patients with tolterodine only.

CONCLUSIONS

Urinary symptoms and urodynamics were highly variable in PD patients, indicating that most patients may benefit from personalized management.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.

Suprameatal urethrolysis with Martius flap for refractory bladder outflow obstruction following stress incontinence surgery in females

AIMS

To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO).

METHODS

A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence.

RESULTS

Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P < 0.01). Among the seven patients who required catheterization preoperatively, five patients (71%) recovered volitional voiding. Two patients (18%) continued to require indwelling or intermittent catheterization and underwent additional surgery for BOO. SUI recurred in one patient (9%). UUI persisted in all four patients who reported this preoperatively.

CONCLUSIONS

SMUM is successful in improving or relieving refractory BOO in this challenging patient population. After TVU, we believe that Martius flap interposition is critical to preventing recurrent fixation of the urethra to the pubic bones and thus achieving improved voiding.

Transperineal Sonography and Urodynamic Findings in Women With Lower Urinary Tract Symptoms After Sling Placement

OBJECTIVES

To evaluate dynamic 2-dimensional (2D) transperineal pelvic sonographic findings and urodynamic studies in women with lower urinary tract symptoms after midurethral sling placement.

METHODS

Transperineal pelvic sonography and urodynamic studies were reviewed from women with a midurethral sling and lower urinary tract symptoms. The shape and sonographic dynamic change of the sling from the rest position to the maximum Valsalva maneuver and back to rest were recorded. Patients were categorized into 3 groups: group I, at rest, the sling lies parallel to the urethral lumen, and during Valsalva, the sling becomes C shaped; group 2, both at rest and during Valsalva, the sling runs parallel to the urethral lumen; and group 3, at rest, the sling is C shaped, and during Valsalva, this curved shape is maintained. For analytical purposes group 3 was compared with groups 1 and 2. Multiple logistic regressions were used to evaluate the association between transperineal pelvic sonography and urodynamic studies.

RESULTS

Seventy-seven women were enrolled. The detrusor pressure at the maximum flow rate was significantly higher in group 3 than groups 1 and 2 (mean ± SD, 36 ± 16 versus 19 ± 11 mm H₂ O; P < .001). The odds of high detrusor pressure (>20 mm H₂ O) in group 3 was approximately 12 times the odds of those in groups 1 and 2. After adjusting for other variables using a multiple logistic regression analysis, a statistically significant association between group 3 and high detrusor pressure persisted (odds ratio, 29.7; 95% confidence interval, 2.949-299.6; P = .0040) persisted.

CONCLUSIONS

Transperineal dynamic 2D sonography can help predict women with high-pressure voiding after midurethral sling placement and aid in the diagnosis of bladder outlet obstruction.

Is the adjustable TVA mesh effective for the long-term treatment of female stress incontinence?

OBJECTIVES

To assess the long-term safety and efficacy of the adjustable TVA mesh in treating stress urinary incontinence.

MATERIAL AND METHODS

Pseudoexperimental study, before and after, conducted in a university urology department. Eighty-two patients were invited to participate from January 2002 to March 2005. Thirty-two patients agreed to participate and were implanted an adjustable TVA mesh. The preoperative study included a medical history review, physical examination with full bladder, flowmetry, residue study, complete urodynamic study and the self-administered questionnaires I-QoL and ICIQ-SF. In the postoperative assessment, the PGI-I questionnaire was added, but a complete urodynamic study was not performed.

RESULTS

Twenty-nine (90.6%) and 28 (87.5%) patients were continent in the stress test at 1 and 10 years, respectively. Twenty (62.5%) and 16 (50%) patients had no urine escape at 1 and 10 years, respectively. Twenty-eight (87.5%) and 25 (78%) patients were satisfied 1 and 10 years after the surgery, respectively. Twenty-eight (87.5%) and 21 (62.5%) patients had a good quality of life at 1 year and at 10 years, respectively. There were no significant complications at the end of the study period.

CONCLUSIONS

Treatment of stress urinary incontinence with the TVA mesh presented a high degree of objective healing and satisfaction at 10 years, with no severe adverse effects. The study showed that satisfaction does not always mean total continence but rather it reflects the improvement of symptoms and consequent quality of life.

Evaluation of obstructed voiding in the female: how close are we to a definition?

PURPOSE OF REVIEW

The difficulties of defining and evaluating bladder outlet obstruction (BOO) in the female patient have been described for several years. This review aims to examine recent literature to summarize progress in the area.

RECENT FINDINGS

Within the last 2 years, functional causes of female BOO have been summarized, new nomograms proposed, several case reports of different causes of BOO have been published and work on surgical outcomes and possible diagnostics reported.

SUMMARY

Women complain of voiding dysfunction because of different reasons. For clinical decision-making, and to evaluate different surgical procedures, finding a way of detecting and quantifying infravesical obstruction is immensely helpful. This review aims to clarify questions concerning definitions of BOO in women and provide an update on recent advances.

Can We State Stable Bladder? How Many Repetitions Should We Do for an Appropriate Demonstration of Involuntary Detrusor Contraction?

AIMS

Involuntary Detrusor Contraction (IDC) may alter therapeutic plans; therefore, urodynamic demonstration (UD) is pivotal. We explore if same session repetitions enhance its demonstration and minimize false-negative results.

METHODS

Two hundred fifty two women (mean age 47 ± 5.7) had 4 full repetitions of UD with the last round filled with 4°C fluid (Ice-water test). IDC was diagnosed if with at least 3 cm H2O after artifacts were ruled out.

RESULTS

44.4% of the cases showed IDC in the first round of the exam but it could be demonstrated in 88.5% of the women if 4 rounds are taken into account. Only 2 cases showed IDC exclusively in the first round. Nine cases (3.5%) showed IDC in the first round and only on Ice-test, while all other IDC-detected cases revealed it in scattered patterns along the repetitions. Likewise, IDC detection on the second, third and fourth rounds varied widely and unpredictably, many failing to show a consistent pattern of presentation after its detection. IDC wave amplitude did not show any correlation to the detection.

CONCLUSIONS

Urodynamic repetition is a necessary procedure where IDC is important to demonstrate, as its false-negative rate is high and its unpredictable pattern of detection may be improved by repetition.

Involuntary detrusor contraction is a frequent finding in patients with recurrent urinary tract infections

OBJECTIVE

To check whether subtle voiding dysfunction is related to recurrent urinary tract infection (rUTI).

METHODS

254 consecutive patients with at least four episodes of urinary tract infection (UTI) were studied. At least three repeat urodynamic evaluations with an additional ice water test to maximize the detection of involuntary detrusor contraction (IDC) were used. Stress urinary incontinence cases were used as controls. Nonparametric univariate and multivariate analyses were used for statistics.

RESULTS

IDC was detected in 83.6% of patients in the rUTI group and in 31.7% in the control group. IDC was <15 cm H2O in 54.7% whereas high-amplitude (>50 cm H2O) IDC was observed in 6.8% in the rUTI group. Female urinary tract obstruction was diagnosed in 16.8% of patients in the rUTI group and in 7.9% in the control group. Residual volume, PdetQmax and Qmax were not predictive of UTI recurrence. Symptoms were similar in both groups.

CONCLUSIONS

Patients with rUTI present with covert bladder dysfunctions represented by detrusor overactivity.

Risk of repeat anti-incontinence surgery following sling release: a review of 93 cases

PURPOSE

Sling procedures are the most common surgery for stress urinary incontinence in women. Lower urinary tract symptoms are well documented complications of these procedures that develop in 5% to 20% of patients. A common treatment for postoperative urinary retention and bothersome obstructive voiding symptoms after anti-incontinence surgery is sling release. While previous studies indicated the risk of recurrent stress urinary incontinence after surgical release of slings, there is a paucity of data on how many patients require repeat anti-incontinence procedures.

MATERIALS AND METHODS

After receiving institutional review board approval we retrospectively reviewed the records of 143 consecutive female sling release procedures performed by 2 subspecialized urologists at our clinic from January 2000 through August 2012. A total of 121 patients underwent documented followup at our clinic, of whom 93 were treated with sling release for obstruction or retention after sling placement. We identified the characteristics of this patient population, specifically the incidence of subsequent anti-incontinence procedures.

RESULTS

Mean ± SD patient age was 58 ± 13.2 years and median patient followup after surgical sling release was 32 months (IQR 6, 67). Of the 93 patients 13 (14%) required a repeat anti-incontinence procedure after sling release at a median of 3 months.

CONCLUSIONS

Sling release remains an important treatment option in patients with obstruction after anti-incontinence surgery. Only a small percent of patients require repeat anti-incontinence surgery for recurrent stress urinary incontinence.