Study design, materials and methods
Expert physicians, members of the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), were queried by means of an online survey regarding the management of bladder outlet obstruction following stress urinary incontinence surgery. The survey has an epidemiological section as well as clinical scenarios.
Results
From 652 SUFU members on the distribution list, 60 answered the questionnaire (9 %).
The number of sling procedures performed over a year among the responders was 1-5 by 3% of them, 6-10 by 7 % of them, 11-20 by 20 % of them, 21-50 by 38 % of them and >50 by 38 % of them.
Among these sling procedures, responders estimated that approximately 15% (SD ±26) were autologous fascial pubovaginal slings.
Responders estimated the prevalence of complete postoperative urinary retention to be approximately 3% (SD ±7).
The prevalence of partial postoperative urinary retention, defined as a post-void residual volume ≥200 ml, was estimated around 8 % (SD ±11).
Of those patients presenting with partial urinary retention, approximately 35 % (SD ±29) were symptomatic.
For a patient suffering from complete urinary retention 48 hours after synthetic mid-urethral sling insertion, most responders would observe for a week before planning an incision of the sling.
If the same woman presented with partial urinary retention, the trend of the majority would be observation for several weeks.
In patient developing complete urinary retention 48 hours following autologous fascial pubovaginal sling procedure, most participants would offer observation for a mean of 6.3 weeks (SD ±3.6) before planning a surgical revision.
In the situation where the same population would present with partial urinary retention, again several weeks observation would be recommended by most of the surgeons quired, who would follow the patients for a mean of 7.1 weeks (SD ±3.8) before planning surgery.
One surgeon used the adjustable synthetic mid-urethral sling (Remeex®) and was able to correct the bladder outlet obstruction by adjusting the tension in an outpatient setting.
Interpretation of results
Sling operations are currently the procedures of choice to treat female stress urinary incontinence and are performed worldwide. They are not without complications and surgeons must be able to manage them.
Nevertheless, the overall prevalence of bladder outlet obstruction resulting in partial and/or complete urinary retention requiring surgical revision is low.
The lack of evidence-based agreement regarding its management poses a dilemma for the operators. Early intervention may induce recurrence of stress urinary incontinence when the bladder outlet obstruction may have resolved spontaneously, whereas expectant management of urinary retention may be onerous for the patient.
There is notably no agreement on the method and timing of surgical revision.
Although our survey couldn’t bring out a consensus on those two parameters, we
highlighted the trend of giving a chance for spontaneous resolution by watchful observation, particularly in the context of partial urinary retention.
We did not investigate the different types of synthetic mid-urethral slings and the way they were inserted. Furthermore, the cost effectiveness of the different strategies would be interesting to evaluate as prolonged use of clean intermittent self-catheterisation carries a cost. Incontinence rate after the surgical revision hasn’t been investigated either.
The use of adjustable sling may reduce the risk of recurrent stress urinary incontinence, but its efficacy has mainly been described in the context of intrinsic sphincter deficiency or after previous anti-incontinence surgeries.