Retropubic Urethrolysis without Resuspension for the Management of Posturethropexy Urinary Retention and Voiding Dysfunction

Military Medicine, Feb 2004 by Woodman, Patrick J, Ruiz, Henry L

Objective: The goal of this study was to determine the efficacy of retropubic urethrolysis without resuspension for the surgical treatment of postoperative urinary retention. Methods: A retrospective chart review was done of six women with posturethropexy urinary retention or voiding dysfunction who underwent retropubic urethrolysis between july 1999 and june 2000. Results: An average of 27.0 (�19.6) months elapsed between obstructive incontinence procedure and urethrolysis. The mean maximum detrusor pressure during voiding was elevated at 52.7 (�31.7) cm H2O. The mean maximum flow rate during voiding was decreased at 16.3 (�10.8) CmH2O. The average postvoid residual volume was 152.9 � 71.6 mL, significantly decreased postoperatively to 36.9 � 40.0 mL (t = 3.37, p = 0.043). Postoperative cystourethroscopy showed a completely free and mobile urethra. In the short term, all patients had resolution of their symptoms. No patient had return of stress incontinence in a mean clinical follow-up of 3.3 � 2.3 months. Conclusions: Our results are comparable to other series of urethrolyses, despite omission of resuspension. Retropubic urethrolysis offers favorable relief of persistent postoperative urinary retention and voiding dysfunction, particularly after retropubic urethropexy.

Introduction

Complete urinary retention is a rare complication of urinary incontinence surgery.1 However, incomplete urinaiy retention and postoperative voiding dysfunction are more common complications and thought, by some, to be the trade-off for "curing" stress incontinence. cases of postoperative de novo instability have been reported in approximately 10% to 12% of suburethral sling or retropubic urethropexy cases.2 When iatrogenic bladder outlet obstruction occurs, the symptoms are often more distressing to the patient than the original problem. Women commonly present with irritative symptoms of urgency, frequent urination, recurrent urinary tract infections, pain, bladder spasms, and urge incontinence.

Postsurgical voiding dysfunction has been tolerated or ignored since the advent of incontinence surgery. There are no universally accepted urodynamic criteria for the diagnosis of female bladder outlet obstruction,3 although some have been proposed,4,5 Unfortunately, women meet objective obstructive urodynamic parameters only 22% to 56% of the time.2,6 Some have suggested that a clear-cut temporal relationship between anti-incontinence surgery and the onset of persistent voiding symptoms is the only absolute criterion for the surgical management of iatrogenic bladder outlet obstruction.2,7,8 When conservative management in the form of clean intermittent catheterization, medication, behavioral modification, relaxation exercises with biofeedback, or pelvic floor stimulation have failed, urethrolysis may be indicated.

Several different approaches to urethrolysis have been described, each technique with its own set of advantages.2,6,8-16 The abdominal (retropubic) approach (Fig, 1), although technically more difficult, is particularly useful when treating bladder outlet obstruction after retropubic urethropexy with success rates of 80% to 93%.2,8,15,16 Arguably, obstetrician-gynecologists perform more retropubic urethropexy procedures than our urological colleagues do. But, a MEDLINE search of the world's literature before January 2002 uncovered only four articles describing the use of retropubic urethrolysis, all appearing in the urological literature.2,8,15,16 However, these authors resuspended the majority of their patients despite evidence to suggest that vaginal-approach urethrolysis without resuspension is an effective treatment for iatrogenic urethral obstruction.11,17 Much of the difficulty in investigating urethrolysis is due to the small numbers of these procedures performed. The development of a Female Pelvic Medicine and Reconstructive Surgery Fellowship at the study institution has given us the opportunity to consolidate procedures done by both services. We describe the first report of using the retropubic approach to uretholysis without regular resuspension for posturethropexy urinary retention and voiding dysfunction.

Methods

A retrospective chart review was done of six sequential women with postoperative urinary retention (postvoid residual >100 mL), voiding dysfunction, and/or persistent de novo irritative voiding symptoms after urethropexy between july 1999 and june 2000 was performed. Median age was 57.7 years (range, 39-74 years). Median clinical follow-up was 3.3 (�2.3) months (range, 1-7 months). Telephone interview was performed at 1 and 2 years. all subjects attributed voiding dysfunction to cystourethropexy4 or suburethral sling.2 Vaginal urethrolyses was unsuccessful in one subject twice previously. Presenting symptomatology is listed in Table I. A total of five women required periodic clean intermittent self-catheterization. Median time from urinary incontinence procedure and urethrolysis was 27 (�19.6) months (range, 7-60 months). all subjects failed conservative therapy (intermittent self-catheterization, pharmacotherapy, behavioral therapy, and/or pelvic floor muscle stimulation).