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Can we predict voiding dysfunction after a mid-urethral sling?

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Predicting postoperative voiding dysfunction following placement of a mid-urethral sling (MUS) for treating stress urinary incontinence is an important area of investigation for incontinence specialists. The reported rate of patients who develop voiding issues after a MUS varies significantly in the literature (7-80%) due to the lack of universal agreement amongst clinicians and researchers as to what constitutes a failed voiding trial after surgery. Moreover, there is no consensus regarding management of the bladder following mid-urethral sling surgery. For example, should a Foley catheter be left in situ at the end of the procedure and for how long?

In order to identify risk factors for postoperative voiding dysfunction following a MUS, a multi-centre case-control study was conducted at 6 tertiary US centres between 2010-2015. Women who underwent a MUS (retropubic 70,9%, transobturator 28.4% and mini-sling 0.6%) over the named period and failed a same-day voiding trial were matched with controls, who had a successful voiding trial at the first attempt. A voiding trial was deemed successful when the patient voided at least two thirds of a retrograde-instilled volume of 300 ml sterile water or had a post-void residual of less than 100 mL. Ten different predictors, including patient demographics, comorbidities, previous anti-incontinence and pelvic floor reconstructive procedures and preoperative multi-channel urodynamics data, were used in a multivariate model, along with intraoperative data, in order to identify risk factors for a failed voiding trial. Overall, 101/363 patients (21.8%) failed the same-day voiding trial, with 90% of those eventually passing the trial with the second attempt on a different date. High comorbidity index score, pathological voiding pattern and increased post-void residual during preoperative urodynamics were strong predictors of a failed voiding trial. On the contrary, neither the type of the MUS nor other parameters of preoperative multi-channel urodynamics, such as detrusor overactivity, were predictive of high residual. Interestingly, patients in whom the initial voiding trial failed remained at increased risk of postoperative urinary tract infection or a later acute retention, even after passing a subsequent voiding trial.

The authors concluded that despite the lack of consensus on a voiding-trial protocol post MUS surgery enhanced counseling based on pre-operative urodynamic data is useful in more complex patients in order to ameliorate patient dissatisfaction regarding treatment.

Additional Information

Ripperda CM, Kowalski JT, Chaudhry ZQ, Mahal AS, Lanzer J, Noor N, Good MM, Hynan LS, Jeppson PC, Rahn DD. Predictors of early postoperative voiding dysfunction and other complications following a midurethral sling. Am J Obstet Gynecol. 2016 Nov;215(5):656.e1-656.e6. doi: 10.1016/j.ajog.2016.06.010. Epub 2016 Jun 16.

Article by Alexandros Derpapas on behalf of the Publication and Communication Committee

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