Review Article
Female Bladder Outlet Obstruction after Anti-Incontinence Surgery
Henry Tran and Matthew Rutman*
Department of Urology, Columbia University, USA
*Corresponding author: Matthew Rutman, Department of Urology, Columbia University, 161 Fort Washington Avenue, Herbert Irving Pavillion 11th Floor, New York, NY, 10032, USA
Published: 03 Mar, 2017
Cite this article as: Tran H, Rutman M. Female Bladder
Outlet Obstruction after Anti-
Incontinence Surgery. Clin Surg. 2017;
2: 1319.
Abstract
Urinary incontinence is a significant medical problem affecting quality of life in women. Numerous
surgical treatment options are available for management of stress urinary incontinence, including
urethral bulking agents, pubo-vaginal slings, retropubic bladder neck suspensions, mid-urethral
slings, and even artificial urinary sphincters. We will discuss the incidence, etiology, diagnosis,
evaluation, and management of outlet obstruction after anti-incontinence surgery in females.
Symptoms of bladder outlet obstruction (BOO) after anti-incontinence surgery can have a wide
range of symptoms, including straining to void, valsalva voiding, sense of incomplete emptying,
weak stream, acute urinary retention, suprapubic fullness or pain in the setting of patients with
prior normal voiding is the single most useful diagnostic parameter. Urodynamic diagnosis of
obstruction is not always straight forward, but is another helpful clinical tool. Management options
for urinary obstruction post anti-incontinence surgery range from conservative to invasive and
surgical treatment options include sling loosening, sling incision and excision, as well as urethrolysis.
Optimal timeline for surgical intervention is still not well defined, but general guiding principles of
management are presented. Comprehensive review of current literature is also performed.
Keywords: Obstruction; Bladder; anti-incontinence surgery
Introduction
Urinary incontinence is a prevalent medical condition impacting quality of life amongst women. The lifetime incidence is reported to be 30-80% [1–3]. The International Continence Society (ICS) reports the annual incidence of stress urinary incontinence (SUI) to be 4-10% [4]. There are a number of surgical treatment options available for incontinence in women, ranging from urethral bulking agents, pubo-vaginal slings (PVS), retropubic bladder neck suspensions, mid-urethral slings, and rarely artificial urinary sphincters [5]. Sling materials include synthetic polypropylene, autologous fascia, and cadaveric fascia. In the United States, the most commonly used operation in the treatment of incontinence currently is sling surgery, including synthetic mid-urethral slings (MUS) or non-synthetic bladder neck slings, which account for 80% of all incontinence surgeries. The next most commonly utilized procedures are the Burch colposuspension (10.5%) and periurethral bulking agents (4.5%) [6,7]. A lot of recent negative publicity regarding synthetic mesh use in vaginal surgery has arisen; however, it is important to highlight that this is only in the setting of synthetic mesh use in transvaginal prolapse repairs and not in incontinence surgery. Numerous organizations including the American College of Obstetrics and Gynecology (ACOG), American Urogynecological Society (AUGS), American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU), and Canadian Urology Association (CUA) support synthetic mesh use in anti-incontinence surgery. Some societies even indicate that polypropylene mid-urethral sling mesh is recognized world-wide as standard of care for SUI [1,8]. Over 3 million synthetic MUS have been inserted since they were introduced in the early 1990s, and 80% of these have been in the USA [9]. Over 99% of AUGS members report using MUS as first line surgical treatment for SUI [9,10]. The integral theory by Petros in 1990 identified laxity in the vagina and supporting ligaments as the cause of associated prolapse, incontinence and pelvic pain [11,12]. Normally, the urethra and bladder neck are supported on the underside by a ‘hammock’ of connective tissue which creates urethral compression and closure during increases in intra-abdominal pressures. Disruption and laxity of the ‘hammock’ cause stress urinary incontinence. Anti-incontinence surgeries inhibit urinary leakage by increasing bladder outlet resistance or via restoring the natural shape and configuration of urethral support. A common complication regardless of the type of anti-incontinence surgery performed is iatrogenic de novo obstruction [13]. We will discuss the incidence, etiology, diagnosis, evaluation, and management of outlet obstruction after anti-incontinence surgery in females.
Incidence and Etiology
Normal voiding requires pelvic floor relaxation and a subsequent
decrease in outlet resistance with a coordinated detrusor contraction
[5,11,14]. The incidence of bladder outlet obstruction (BOO) after
anti-incontinence surgery ranges from 2.5-24% [15–21]. Initially,
it was believed that sling procedures had a lower overall incidence
of bladder outlet obstruction compared to colposuspension, but in
2010, a meta-analysis showed that amongst all anti-incontinence
surgeries, there is a similar incidence of de novo lower urinary tract
symptoms (LUTS), and obstructive voiding symptoms [1,22]. 1-10%
of patients have urinary retention persisting beyond 28 days after
surgery [23]. The incidence of BOO is also likely under reported
with a common explanation felt to be patient satisfaction as a result
of being dry leading to less reporting of de novo lower urinary tract
symptoms. In addition, 50-75% of patients who do need sling revision
seek a different surgeon which may lead to fewer cases of BOO being
reported [1,24].
Although BOO is a complication in any type of anti-incontinence
surgery, the reported incidence is variable amongst the different
procedures. In general, it appears that MUS have lower rates of
obstruction (4%) compared to other transvaginal procedures
such as PVS, Marshall-Marchetti Krantz (MMK), and Burch
colposuspension [13,23,25,26]. On the contrary, Blaivas et al. [27]
showed that the incidence of retropubic slings requiring intervention
is 0-8.9% compared to transobturator tape (TOT), which is 0-21.3%
[1]. There are a few mechanisms of obstruction following antiincontinence
surgery. Obstruction occurs when there is increased
dynamic or static change in the urethral resistance [24]. Obstruction
after incontinence surgery is generally related to one of several
technical factors. During retro-pubic or transvaginal suspension
surgery, increased urethral deviation scarring from prior surgery, or
kinking can occur if the sutures are placed too medially. Additionally,
sutures or slings placed too distally can physically obstruct and kink
the distal urethra. Finally, the most common cause is an overly tight
suture or sling during attempt to recreate the natural hammock
configuration, leading to hyper-suspension and subsequent bladder
neck and/or proximal urethral obstruction [28]. In a study of 3747
women undergoing anti-incontinence surgery, the problem of
obstruction after post-incontinence surgery appears to be improving.
This is reflected by a decreasing incidence of reoperations for sling
incision or loosening; 1.2% of retropubic surgeries and 1.9% for TOT
[29]. The TOMUS trial studied 528 patients randomized to either
retropubic or transobturator sling insertion; 9 patients developed
voiding dysfunction necessitating catheterization or surgery. The
overall incidence of iatrogenic obstruction was low at 3%, but the
results suggested that retropubic slings may be more obstructing than
TOT [26]. Another comprehensive study looked at 188,000 women
with MUS insertion followed for 9 years [30]. Causes and rates of
sling revision and removal were studied; over 9 years, 1.3% of patients
required sling revision/removal for urinary retention. Also, women
aged 18-29 and those with concomitant anterior or apical prolapse had
a higher incidence of requiring sling revision or removal. In addition
to iatrogenic obstruction from improper technique, (commonly
over tensioning of the sling) other causes of postoperative de novo
obstruction include preoperative detrusor dysfunction. For example,
valsalva voiding, increased preoperative detrusor pressure, lower
preoperative peak urinary flow rates have all been associated with de
novo postoperative obstruction [24,31]. These factors likely indicate
some degree of pre-existing dysfunctional voiding from impaired
contractility.
Diagnosis and Evaluation
Bladder outlet obstruction after anti-incontinence surgery can
present with a range of symptoms, often vague and subtle, mandating
a high index of suspicion. Perhaps the most important factors in
diagnosis are symptomatology and the temporal relationship to
sling surgery. Symptoms such as straining to void, valsalva voiding,
sense of incomplete emptying, weak stream, acute urinary retention,
suprapubic fullness or pain in the setting of patients with prior
normal voiding are the most useful diagnostic parameters [28].
Other symptoms that can point to the diagnosis of obstruction,
although not specific, include de novo overactive bladder (frequency,
urgency, urgency incontinence). Symptoms occurring after sling
insertion point towards a causal relationship between surgery and
symptomatology. These symptoms are less obvious than urinary
retention, and can resolve over time. Conservative treatments can be
attempted initially, including timed voiding, pelvic floor relaxation/
physiotherapy, and self-clean intermittent catheterizations [6,32,33].
Important components in evaluation include physical examination
findings of urethral hyper-suspension. In this case, the urethra and
urethral meatus appear to be pulled upwards towards the pubic bone
and ‘fixed’. Any bladder prolapse should also be noted as this can
be obstructive [28]. Other useful diagnostic tests include urinalysis,
urine culture, urodynamics and uroflowmetry. Especially important
are comparisons of pre and post-operative detrusor pressure, flow
rate, and post-void residual. Cystoscopy can be helpful to look for
urethral angulation or kinking. Other important things to identify
include obvious scarring, occlusion, mesh erosion or visible sutures
that may be contributing to symptomatology [1,14,34,35]. Standing
cystogram with and without straining can look at the amount of
bladder and urethral prolapse and bladder displacement. Voiding
cystourethrogram (VCUG) can look at dynamic bladder, bladder
neck, and urethral anatomy during the voiding phase [28]. When
evaluating and considering the diagnosis of post anti-incontinence
obstruction, differentiating between true anatomic obstruction and
functional obstruction is important. Functional obstruction can be
due to dysfunctional voiding (increased EMG activity during voiding
indicative of poor relaxation of the pelvic floor). These patients
respond well to pelvic floor muscle therapy with biofeedback and
pelvic floor relaxation, as opposed to re-operation [14].
Bladder outlet obstruction in women can also be diagnosed using
urodynamic parameters; however, the definition and diagnosis is not
standardized. Blaivas and Groutz introduced a nomogram with 4
categories (no obstruction, mild, moderate, and severe obstruction)
calculated using PdetQmax and Qmax. A PdetQmax >107 cm H2O is
severe obstruction, PdetQmax between 57-107 cm H2O is moderate
obstruction. Other definitions of obstruction include Chassagne
(PdetQmax >20 cm and Qmax< 15mL/s), Lemack and Zimmern
(PdetQmax>21, Qmax< 11mL/s) [36], and Defreitas (PdetQmax >25, Qmax<12 mL/s) [37]. The highly variable nature of these parameters gives
insight into the difficult nature of diagnosing obstruction in women
using urodynamics alone. Findings on uroflowmetry can also be
highly variable. Rodrigues et al. [38] found that in 302 women with
voiding lower urinary tract symptoms or urinary retention after antiincontinence
surgery, pressure-flow patterns were highly variable,
ranging from 1) elevated pressure and poor flow, 2) normal pressure and poor flow, 3) normal pressure and flow, but prolonged flow time,
4) poor detrusor contraction and elevated PVR, and 5) increased
pressure and high flow. Other important variables that can change
with obstruction include increased voiding time and mean detrusor
pressure, and decreased maximum flow rate.
Management and Treatment
Patients with diagnosis of iatrogenic bladder outlet obstruction
definitely warrant treatment. Animal studies in rats show that
even partial urethral obstruction leads to 3 different changes in the
bladder over time. The first is increasing bladder capacity with early
inflammation (0-2 weeks), followed by smooth muscle hypertrophy
where bladder contraction strength increases (2-8 weeks), and finally
bladder decompensation via late collagen deposition where capacity
and contractility are affected [39]. Similar changes are hypothesized
to occur in humans. Various management options for obstruction
are available, ranging from conservative to pharmacologic to
surgical. Conservative treatment options include self cleanintermittent
catheterization. This is a good option until resolution
of obstruction in patients with transient obstruction. Patients with
longstanding obstruction can also be managed this way, as a subset
of them may not want another operation which carries the risk of
recurrent incontinence. In addition, pharmacotherapy can be utilized
and targeted at the most bothersome LUTS. Anticholinergics or
beta 3-agonists can help relieve storage LUTS [1]. Stand-alone
anticholinergic or beta 3-agonist medications can worsen incomplete
emptying and retention symptoms, and should be avoided in truly
obstructed patients. Alpha blockers have also been advocated in
patients with minimal or very mild obstruction. These medications
will not affect sling tension, but may decrease bladder neck outlet
resistance enough to relieve outlet obstruction without more invasive
therapies [24]. Other reported conservative measures for management
of true anatomic obstruction include urethral dilation, which is
performed with urethral sounding and downward traction to loosen
the sling. Some series report >80% improvement in obstruction using
this technique alone; however, this is an imprecise operation and
damage to surrounding tissues can occur [1,40].
Another important factor for treatment consideration is the
timeline of when to apply intervention. Optimal timeline for surgical
correction of obstruction is not well defined. Historically, patients
who were obstructed after pubo-vaginal sling surgery were felt
to need time to allow the bladder to adjust to the sling. Generally,
timing of intervention depends on the type of anti-incontinence
surgery. Patients with pubo-vaginal slings can undergo conservative
management for 8-12 weeks before a decision for revision surgery. The
logic behind this is that bladder neck slings intrinsically are believed
to be more obstructive to begin with and some breakdown of the nonsynthetic
material can occur over time, loosening the obstruction
naturally [6]. With mid-urethral synthetic slings, intervention can be
done much earlier at 2-4 weeks because these slings are permanent
and do not undergo further remodeling to loosen [41]. Also, earlier
management is ideal before significant tissue in-growth occurs [24].
Surgical treatment options include formal sling loosening, release by
incision, sling excision, and urethrolysis [42]. Studies do show though,
that earlier management and treatment of obstruction may lead to
better outcomes [6]. South et al. [43] evaluated 112 females with sling
release for de novo LUTS, and patients who had sling release <1 year
had better improvement in LUTS compared to those who had sling
release > 1 year. Patients with obvious and persistent obstruction
greater than 48 hours after sling surgery may benefit from immediate
sling loosening or incision/excision before tissue reaction makes
revision surgery more difficult [1]. Sling loosening is done simply
by opening up the vaginal incision, and using a right angle dissector
between the sling and the urethra to place downward traction on the
sling by 1 to 2cm. Up to 96% of patients see improvement without
significant compromise in continence [44–46]. Another treatment
option is sling incision (midline) or partial or complete sling excision;
patients do run the risk of recurrence of SUI and may still have
persistent LUTS despite this treatment. The risk of recurrent SUI
following sling excision is reported at 14-19% [40,43,47–53]. Various
methods of sling incision have been reported. These include single
lateral incision [54], midline incision [55], and bilateral incision (2
and 10 o’clock) [56]. Klutke et al. [40] demonstrated early on in 2001
the efficacy of sling loosening or incision in a cohort of 600 patients
who underwent TVT insertion; 17 patients developed urinary
retention and underwent sling release (either single incision release or
sling loosening) at a mean of 64 days (6-228 days) after the procedure.
All patients were able to void within 24 hours of release, and 16 of 17
remained dry. One patient who had an intraoperative urethral injury
that was repaired but had persistent incontinence and went on to
have another subsequent successful anti-incontinence surgery. Sling
incision can be done in patients who have had either synthetic MUS
polypropylene mesh orautologous pubo-vaginal slings. Urethrolysis
is not the only treatment available for patients following a pubovaginal
sling placement. These patients can be managed with a
simple sling incision [50,51,57,58]. In patients who undergo excision,
typically a partial excision of the sling is done initially; however,
complete excision may be necessary for patients with pelvic pain, or
mesh exposure [1]. Other than sling incision or excision, urethrolysis
is another option to relieve obstruction. Urethrolysis and excision
lead to much more dissection and urethral mobility compared to
incision alone; also, incision is less likely to work after a few weeks
from original surgery due to scarring and tissue reaction/interaction
with the sling [6]. Several surgicaloptions exist for urethrolysis, which
can be accomplished via transvaginal, retropubic, or supra-meatal
approach. Urethrolysis surgery is typically reserved for patients who
have severe obstruction or failed prior sling loosening or incision.
At time of urethrolysis, tissue interposition with a Martius flap is
sometimes utilizedto decrease subsequent risk of fibrosis and also
increase urethral support [31]. Success rates range from 65-93%
and recurrent incontinence occurs in 0-19% [31]. Due to the risk
of recurrent incontinence in patients that opt for sling incision,
excision, or urethrolysis, there is some controversy about whether or
not to perform a concomitant anti-incontinence procedure. There are
no randomized trials using this approach, and the available literature
suggests that rates of recurrent incontinence are the same regardless
of whether or not prophylactic anti-incontinence surgery is done
[59]. We prefer to not do a concomitant anti-incontinence procedure
as this may obscure the clinically important question of whether the
sling incision, excision, or urethrolysis relieved the obstruction and
if patients had symptomatic improvement. Videourodynamics has
been recommended as an important diagnostic tool in patients after
incision, excision, or urethrolysis [60]. Management of patients with
persistent urinary retention after revision surgery or persistent LUTS
is a challenging problem. Patients should be counselled about repeat
UDS testing at 3 months, and if persistent obstruction is identified,
repeat urethrolysis can be attempted with high success rates of 91%
[61]. Patients that prove to not be obstructed on subsequent testing
but have persistent LUTS should have therapy directed towards the bladder [6]. Unfortunately, over 50% of patients with overactive
bladder symptoms (OAB) prior to urethrolysis can have persistence
of OAB symptoms following urethrolysis or sling take-down [62].
These patients have lower overall satisfaction. Starkman et al. [63,64]
demonstrated that many of these patients can be effectively treated
with anticholinergics, but for those who fail medical therapy, Botox
and sacral neuro modulation can be used for this complex patient
population.
Conclusion
Voiding dysfunction is a significant problem and can occur in 5-10% of patients following surgery for treatment of stress incontinence. The diagnosis of iatrogenic obstruction after incontinence surgery is not always obvious and there are still no standardized criteria. Hence, close follow-up and monitoring of patients is essential so that timely diagnosis and intervention can be done before the development of permanent bladder dysfunction. A high clinical index of suspicion needs to be maintained in patients with new onset voiding symptoms after surgery. Interventions for treating obstruction include conservative (CIC, biofeedback, pelvic floor relaxation), medical (alpha blockers, anticholinergics, beta 3-agonists), and surgical (sling incision, excision, urethrolysis). Medications do not appear to have significant clinical efficacy because they do not correct the underlying anatomical defect. The choice of intervention depends on the degree of obstruction and underlying etiology causing the obstruction. Patients with severe incontinence preoperatively may be content and best managed with CIC due to high risk of recurrent incontinence. The optimal timing for intervention is still not well standardized, and more studies are needed in this area. Patients should also be warned about possible recurrence of incontinence and persistence of storage symptoms. Complex problems may arise after seemingly simple antiincontinence surgeries; hence, it is important that these operations are performed by surgeons with expertise in voiding dysfunction, so that complications may be recognized and adequately managed.
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