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abstract

236 - EARLY MIDURETHRAL SLING LOOSENING IN PATIENTS WITH POSTOPERATIVE VOIDING DYSFUNCTION

236

EARLY MIDURETHRAL SLING LOOSENING IN PATIENTS WITH POSTOPERATIVE VOIDING DYSFUNCTION

P. UBERTAZZI1, C. I. SANDOR 2, L. I. PAVAN 3, C. FONSECA 4, R. PEREZ 4, V. MONTUOSO 5, M. N. NAPOLI 5;
1GYNECOLOGY, Hosp. Italiano de Buenos Aires, Buenos Aires, Argentina, 2Hosp. Italiano, Buenos Aires, Argentina, 3Hosp. Italiano de Buenos Aires, Buenos aires, Argentina, 4Hosp. Italiano de Buenos Aires, Buenos Aires, Argentina, 5Hosp. italiano de buenos aires, buenos aires, Argentina.

Introduction: Midurethral slings (MUS) are currently considered the gold standard for treatment of stress urinary incontinence (SUI), since they offer high efficacy and low complication rates. Voiding dysfunction (VD) is a frequent postoperative complication, with a reported incidence that varies between 1.6 and 26% (1). At the moment there is no consensus regarding its optimal treatment. Options include expectant management (bladder catheterization or sterile intermittent catheterization) and in cases of persistent VD, surgical release (early loosening, sling incision or urethrolysis). Our hypothesis is that early loosening of the MUS can resolve VD without affecting quality of life by maintaining long term continence
Objective: The aim of the study was to describe the management and follow up of a series of patients who experienced postoperative VD and underwent early loosening of MUS
Methods: We retrospectively analyzed a cohort of 10 consecutive patients who underwent anti-incontinence surgery in the urogynecology service of a third-level university hospital between January 2006 and June 2016 and required early MUS loosening for VD. Patients who reported feeling incomplete bladder emptying or slow urine stream after surgery were evaluated by ultrasound. If post-voiding residual urine volume (PVR) was greater than 30% or the patient presented acute urinary retention, a bladder catheter was placed. PVR volume was evaluated on postoperative days 2 and 5. If VD persisted and other causes of VD such as hematoma, edema or bladder overdistention were ruled out, early surgical loosening of the MUS was performed (before day 10). The data was collected from the specific database of the urogynecology service and the electronic medical records.Patients were assessed using specific questionnaires (UDI6 - IIQ7 - ICIQ SF) and ancillary studies (uroflowmetry and bladder ultrasound for PVR measurement as well as transperineal ultrasound for assessment of MUS position)
Results: A total of 715 women with SUI underwent MUS placement during this period. Ten patients (1.4%) referred postoperative VD and were subjected to early loosening. In 8 cases a transobturator MUS had been used and a retropubic sling had been placed in the remaining 2 cases. Six patients had also undergone concomitant vaginal prolapse correction surgery. Over the immediate postoperative period, 3 patients presented with urine acute retention and bladder overdistention.All patients with VD had a transurethral catheter placed until sling loosening, which was performed on the 6th postoperative day (range 2-7 days). No surgical complications were registered. After the procedure, 6 patients (60%) continued to experience VD, including the 3 patients who had initially presented with bladder overdistention. Four patients remained with a urinary catheter for 7 days until VD resolved. Two patients required intermittent catheterization during 6 weeks after sling mobilization. After this period, all patients completely resolved their VD.All patients had long-term evaluations, with a mean time of 32.1 months (Range 6-60). Compared uroflowmetry showed an average Q-max of 18.6 ml/sec (Range 10-33). The PVR average as assessed through pelvic ultrasound was 17% (Range 0-31). The mean sling to pubic symphysis distance measured by transperineal ultrasound was 11.8 mm. (Range 9-16).Specific questionnaires showed little impact on quality of life: the mean UDI-6 score was 22/100 (range 0-50) and the average IIQ7 score was 17/100 (range 0-52). Only 2 patients (20%) reported SUI, but referred symptom improvement according to comparative ICIQ SF scores (preoperative average 17 vs postoperative average 5)
Conclusions: In our experience, early loosening of MUS proved to be effective treatment for VD, according to standardized urodynamic tests, ultrasound PVR measurement PVR and sling localization through transperineal ultrasound.Only two patients presented residual SUI, but without major impact on quality of life. Given that VD can be caused by other reasons, close monitoring and strict postoperative follow-up of patients is crucial. A significant weakness of our study is our small patient number, which does not allow us to draw definitive conclusions despite the long period of analysis and follow up. Large scale, comparative studies are necessary, but the low incidence of this event makes them difficult to achieve.In conclusion, we have found that early surgical MUS loosening is an effective and safe technique for rapid resolution of DV which offers prompt recovery of spontaneous micturition, a low incidence of postoperative SUI and does not seem to affect long-term continence
References: Int Urogynecol J. 2015 Nov;26(11):1657-60