Obstruction Following Anti-Incontinence Procedures: Diagnosis and Treatment with Transvaginal Urethrolysis

Abstract

We reviewed the charts of 41 patients who underwent transvaginal urethrolysis and resuspension of the bladder neck by the Raz technique for urethral obstruction with or without stress urinary incontinence following anti-incontinence surgery. We sought to evaluate the effectiveness of the procedure as well as to determine any factors that had an effect on the outcome of surgery. Patients were evaluated for obstruction and stress urinary incontinence by history, physical examination, video urodynamics (or multichannel urodynamics plus cystogram and voiding cystourethrography) and cystoscopy. All patients reported normal emptying before the procedure that caused obstruction. Several variables were evaluated for individual predictive values for outcome, including type of surgery causing obstruction, number of previous anti-incontinence procedures, urodynamic evidence of obstruction (high pressure, low flow), instability, concomitant stress urinary incontinence and total urinary retention, which were evaluated by the Fisher exact test, and the amount of post-void residual, bladder capacity, maximum detrusor pressure, maximum urinary flow and interval since surgery causing obstruction, which were evaluated by logistic regression analysis. Mean patient age was 59 years (range 26 to 86 years) and mean followup was 21 months. A total of 19 patients (46%) suffered from concurrent stress urinary incontinence, 23 (56%) had urodynamic evidence of obstruction (high pressure/low flow) and 6 (15%) had only radiographic or endoscopic evidence with a deviated or kinked urethra. Postoperatively, 29 patients (71%) voided normally without significant residuals. Eight patients (20%) remain on self-catheterization and 1 has persistent stress urinary incontinence. When individual variables were evaluated to determine the predictive values with respect to outcome of urethrolysis, only the preoperative post-void residual was statistically significant (the greater the post-void residual, the more likely was failure, p = 0.021). The presence or strength of the detrusor contraction preoperatively and pressure-flow analysis did not predict outcome. Of the patients with stress urinary incontinence 15 (79%) were cured and 3 (16%) were significantly improved with rare stress urinary incontinence not requiring protection. Overall, 33 patients (80%) had some benefit from surgery. Patients who emptied normally before and anti-incontinence procedure that causes obstruction or impaired emptying should not be excluded from urethrolysis based on low detrusor pressures or pressure-flow analysis alone. Simultaneous radiographic imaging and endoscopy may help to select certain patients with obstruction.