EARLY VOIDING DYSFUNCTION AFTER MID-URETHRAL SLING: COMPARISON OF TWO MANAGEMENT APPROACHES
A. BRENNAND, C. BIRCH, M. ROBERT, S. KIM-FINE;
Department of Obstetrics & Gynecology, Univ. of Calgary, Calgary, Canada.
Introduction: Early voiding dysfunction (EVD) presenting as post-operative urinary retention (UR) is a known complication of midurethral sling surgery (MUS)1. Management of post-operative retention is not standardized.
Objective: Our group aimed to characterize management techniques used at our centre with resulting patient outcomes such as resolution of UR, persistent VD symptoms, and recurrent stress incontinence.
Methods: A prospective cohort of women undergoing surgery in the two year window of March 2014-2016 was designed. All women recognized as requiring catheterization at post operative day 7 or beyond their MUS procedure were invited to take part. Baseline questionnaires regarding urinary symptoms were completed. Management plans were determined by surgeon and patient in shared decision making, as per usual clinical practice. Questionnaires were re-administered at 3 and 6 months post-MUS surgery. Timing and type of any surgical intervention for EVD was recorded.
Results: 31 women were clinically recognized as experiencing EVD on post-operative day 7 (or beyond). All enrolled, and complete 6-month follow-up was available for 96.8% of participants (n=30). Majority of women received a retropubic MUS (n=28), 3 women received a transobturator MUS.
Two predominant management plans were identified: planned “early sling mobilization”2 to pull down the sling intact (n=10) or continued catheterization3 with delayed sling lysis as needed (n=21).
In the “mobilization” group, UR resolved in 8/10 women after one intervention. Two women required a second “mobilization”. All the women in the “mobilization” group had resolution of their need for catheterization after 1 or 2 loosening procedures. Approximately half of women (n=10, 47.6%) in the continued catheterization group had spontaneous resolution of their UR without surgical intervention, the other half (n=11, 52.4%) elected to undergo sling lysis within the first 6 months after MUS. Of the 11 women who underwent sling lysis, need for catheterization resolved in most (n=10).
None of the women in the planned “mobilization” group reported recurrent SUI at 6 months. In the group who planned to continue catheterization in attempts to avoid surgical intervention, 45% (n=9/20) of women reported recurrent SUI at 6 months. Recurrent SUI rates between the two management approaches were statistically different (0% vs. 45%, p=0.013). Majority of the women experiencing recurrent SUI had undergone sling lysis (n=7).
Conclusions: Patients experiencing EVD after MUS can be informed that UR will resolve for 50% with prolonged catheterization. Intervention with early sling mobilization should be an option for those patients not comfortable with prolonged catheterization. Early intervention by mobilization may provide lower risk of recurrent SUI, compared prolonged catheterization, due to avoidance of sling lysis.
References: 1. Dawson T, Lawton V, Adams E, Richmond D. Factors predictive for post-TVT voiding dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(11): 1297-302.
2. Price N, Slack A, Khong SY, Currie I, Jackson S. The benefit of early mobilization of tension- free vaginal tape in the treatment of post-operative voiding dysfunction. Int Urogynecol J. 2009; 20: 855-8.
3. Elliot C, Comiter C. Evaluation and Management of Urinary Retention and Voiding Dysfunction After Sling Surgery for Female Stress Urinary Incontinence. Curr Bladder Dysfunct Rep. 2012; 7:268-74. 96