Study design, materials and methods
The study was started after obtaining approval from institutional review board and a written informed consent was obtained from all patients before being included in the study. We included females who had all the following features at presentation: maximum flow rate of urine < 12 mL/second, inadequate funnelling of bladder neck on voiding cysto-urethrogram(Image 1), post void residual urine greater than 100 mL, sustained detrusor contraction > 25 cmH2O at Qmax and a normal urethral calibre. Absence of urethral stricture disease/ normal calibre of urethra were confirmed with gentle urethral calibration. Preoperative evaluation comprised of complete history including an International Consultation on Incontinence Questionnaire - Female Lower Urinary Tract Symptoms Long Form (ICIQ FLUTS LF), physical and a focused neurological examination. Local examination to rule out anatomic causes of obstruction was carried out. Uroflowmetry, voiding cystometrogram and cystourethtroscopy were performed in all patients before surgery. Alpha blockers were discontinued at least two weeks prior to surgery. Surgical procedure involved endoscopic incisions at five and seven 'O clock positions on bladder neck with Collings knife using monopolar diathermy through a 24 Fr resectoscope sheath (Image 2). The incision was continued through proximal third of urethra and stopped just before reaching mid urethra. All patients were subjected to a postoperative symptom score and uroflowmetry, at a follow up of three and twelve months. Preoperative and postoperative variables like Qmax, postvoid residual urine (PVRU), ICIQ FLUTS LF score and quality of life score (QOL) were compared using paired t test. The differences were considered statistically significant only at a P value of less than 0.05.
Results
This study included 48 females studied over a period of six years. They were aged between 23 to 66 years (mean age of 47 years). The patients had a mean body mass index of 27.3, three patients were hypertensive, three were hypothyroid and one was diabetic. Most patients (87.9 %) presented with complaints of frequency, hesitancy and straining at micturition. Recurrent UTIs were seen in 11 patients and, vesico-ureteral reflux on voiding cystourethrogram was seen bilaterally in two patients and unilaterally in four patients. Fourteen patients had been on clean intermittent self-catheterisation preoperatively. None of our patients had history of acute urinary retention, stress or urge urinary incontinence. All the patients were followed up for a minimum period of one year. The median follow up of patients in the study was 33.4 months. Preoperatively Qmax, mean ICIQ-FLUTS LF score, PVRU and mean quality of life score were 7.14 mL/sec, 19.4, 139 mL and 4.5 respectively. Postoperatively the same variables were 19.37 mL/sec, 7.6, 32 ml and 2.3 respectively.
Interpretation of results
On comparing the preoperative and postoperative variables recorded at twelve months a statistically significant difference was noted in all four variables. The procedure was successful in first attempt in 87.5% of the patients. Six patients who had a Qmax of 10< mL/sec postoperatively with recurrent/persistent symptoms underwent a repeat procedure.
Stress urinary incontinence was diagnosed clinically in four patients postoperatively. All the patients had mild or moderate SUI as per ICIQ FLUTS LF questionnaire score standard (one or two points) and were managed conservatively with duloxetine without the need for any surgical intervention.