Managing Voiding Dysfunction After Sling Procedures

CONTINUING MEDICAL EDUCATION
CME articles are also available at www.femalepatient.com
Managing Voiding Dysfunction
After Sling Procedures
Bogdan Grigorescu, MD; George Lazarou, MD, FACOG
Women who undergo a sling procedure
to treat stress urinary incontinence
may occasionally find themselves
at the opposite end of the spectrum
postoperatively, experiencing voiding
difficulty and urinary retention. Although
these sequelae often resolve with conservative
measures, patients requiring
additional surgery can generally expect
a satisfactory outcome.
Bogdan Grigorescu, MD, is Attending Physician, Division
of Female Pelvic Medicine and Reconstructive Surgery,
Department of Obstetrics and Gynecology, Ochsner
Medical Center, New Orleans, LA. George Lazarou, MD,
FACOG, is Associate Clinical Professor, Albert Einstein
College of Medicine; and Chief of Gynecology, Division
of Urogynecology & Reconstructive Pelvic Surgery, Winthrop-University
Hospital, Mineola, NY.
Urethral sling procedures are
widely used to manage stress
urinary incontinence (SUI), with
reported success rates of 75% to
93%. 1-3 Suburethral slings restore
the support of the urethrovesical junction, and
enhance the coaptation of the urethra. 4 Initially,
pubovaginal slings made of autologous
fascia were placed at the level of the bladder
neck, and then allograft and xenograft slings
were used. With the increasing demand for
minimally invasive techniques, midurethral
sling procedures—eg, the vaginal sling using
tension-free vaginal tape (TVT) and the transobturator
(TOT) sling—were developed.
Despite widespread adoption and high patient
satisfaction rates, midurethral sling procedures
are not without complications, including voiding
dysfunction (VD), de novo urinary urgency/
urge incontinence, hemorrhage, vaginal or
CONTINUING MEDICAL EDUCATION
Estimated time to complete this activity: 1 hour.
Goal
To explore the causes and solutions for voiding dysfunction following urethral sling
procedures in women.
Intended Audience
This CME Activity is designed for ObGyns, primary care physicians, and nurse
practitioners.
Learning Objectives
After completing this activity, the participant should be better able to:
1. Clarify the causes and incidence of voiding dysfunction after urethral sling surgery.
2. Outline the diagnosis of voiding dysfunction and urinary retention.
3. Describe the performance of urethrolysis and sling incision to correct post-sling
voiding dysfunction.
Accreditation
This activity has been planned and implemented in accordance with the Essential
Areas and Policies of the Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of Albert Einstein College of Medicine and
Quadrant HealthCom Inc. Albert Einstein College of Medicine is accredited by the
ACCME to provide continuing medical education for physicians.
Albert Einstein College of Medicine designates this educational activity for a
maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
This activity has been peer reviewed and approved by Brian Cohen, MD,
Professor of Clinical ObGyn, Albert Einstein College of Medicine. Review date:
December 2008.
Participants who answer 70% or more of the questions correctly will obtain
credit. To earn credit, see the instructions on page 45 and mail your answers according
to the instructions on page 46.
Conflict of Interest Statement
The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine
requires that authors participating in any CME activity disclose to the audience any
relationship(s) with a pharmaceutical or equipment company. Any author whose
disclosed relationships prove to create a conflict of interest, with regard to their
contribution to the activity, will not be permitted to publish.
The Albert Einstein College of Medicine also requires that faculty participating in any
CME activity disclose to the audience when discussing any unlabeled or investigational
use of any commercial product, or device, not yet approved for use in the United States.
Dr Grigorescu reports no conflict of interest. Dr Lazarou reports that he is member
of the speaker’s bureau for Astellas Pharma US, Inc; GlaxoSmithKline; and Novartis
Pharmaceuticals Corporation. He is also a consultant for the Coloplast Group and
Boston Scientific Corporation. The disclosure reported by the author presents no
conflict of interest to this article. The authors report no discussion of off-label use. Dr
Cohen reports no conflict of interest. The staffs of CCME of Albert Einstein College
of Medicine and The Female Patient have no conflicts of interest with commercial
interest related directly or indirectly to this educational activity.
40 The Female Patient | VOL 34 JANUARY 2009 www.femalepatient.com

GRIGORESCU and LAZAROU
urethral erosion/infection, and lower urinary
tract and nerve injury. 5 This article discusses
voiding dysfunction associated with midurethral
sling procedures.
INCIDENCE AND ETIOLOGY
Voiding dysfunction is a well-documented
complication of suburethral sling procedures.
Most cases of VD are temporary, and resolve
by the end of the first postoperative week. The
incidence of VD lasting more than 3 months
postoperatively is unknown, as comparative
studies are lacking; however, reported VD
associated with TVT and TOT procedures
ranges from 1% to 3%. 6,7 The broad divergence
in reported VD rates may result from
underdiagnosis and/or inadequate work-up
of patients. Voiding dysfunction may be a
consequence of excessive tension on, or
improper placement of, the sling. 4 Several
intrinsic factors may affect the patient’s voiding
mechanism after sling surgery, as well.
Simultaneous pelvic organ prolapse (eg, cystocele)
that was not corrected at the time of
the sling procedure may cause urethral
obstruction and VD. Moreover, after sling
surgery, patients with preoperatively impaired
detrusor contractility or patients who habitually
void using the Valsalva technique may
experience postoperative VD because of the
increased urethral resistance. 4
CLINICAL PRESENTATION
Common presenting symptoms of VD are de
novo urgency, urge incontinence, incomplete
bladder emptying, and urinary retention. 5 The
majority of women (55% to 93%) present with
irritative symptoms in the immediate postoperative
period. 8 Diagnosing urethral obstruction
may involve urodynamic evaluation, cystourethroscopy,
and vaginal examination.
DIAGNOSIS
History and Physical Examination
The temporal relationship of the sling procedure
to the occurrence of VD symptoms is
paramount. It is also important to study the
records of the patient’s preoperative voiding
function. The catheterized or bladder ultrasonographic
postvoid urine residual volume may
give important information regarding preoperative
voiding function. Physical findings are
normal in most patients, but severe cases may
demonstrate a hypersuspended urethra, or
retropubic angulation of the anterior vaginal
wall at the midurethra and
proximal urethra. Vaginal
examination may also reveal
sling extrusion or anterior
vaginal wall prolapse. 4,5
Urodynamics
Several criteria have been proposed
to characterize urodynamic
urethral obstruction,
but these definitions have not
yet been universally accepted.
In a study that used the criteria
of detrusor pressure at peak
flow of more than 30 to 40 cm
H 2
O and a peak flow rate of less
than 15 mL/sec, 33% of patients
FOCUSPOINT
Simultaneous
pelvic organ
prolapse that was
not corrected at the
time of the sling
procedure may
cause urethral
obstruction
and VD.
with symptoms of VD did not meet the standard
of urodynamic urethral obstruction,
although they probably had obstruction based
on the temporal relationship of the sling to the
occurrence of VD symptoms. 8 In a comparison
of patients who met the urodynamic criteria
for urethral obstruction with those who did
not, the two groups benefited equally from
urethrolysis; thus, urodynamics did not help
predict the surgical outcome. 9 Although urodynamics
may not be required in the evaluation
of urethral obstruction following sling
surgery, it may yield important information
about the patient’s condition. Furthermore,
borderline urodynamic findings should not be
used to exclude patients from sling revision. 5
Cystourethroscopy
Cystourethroscopy performed with a 0° or 30°
lens may provide useful information in the
diagnosis of urethral obstruction, revealing a
posterior urethral “knuckle,” limited urethral
sagittal rotation, or urethral erosions. Moreover,
cystourethroscopy or a cotton swab test
can show whether the urethral axis has deviated
from the horizontal. Urethral obstruction
after sling surgery may demonstrate negative
angulations, indicating retropubic deflection of
the urethra. Cystourethroscopy can also provide
reassurance that no suture or sling material
has eroded through the bladder or urethra
to cause irritative bladder symptoms. 5,10
TREATMENT
Conservative Treatment
Transient VD that occurs within the first
3 months after suburethral sling surgery is
common, and is often managed with indwelling
The Female Patient | VOL 34 JANUARY 2009 41

CONTINUING MEDICAL EDUCATION
Managing Voiding Dysfunction After Sling Procedures
FOCUSPOINT
Significant
improvement in
voiding efficiency
with urethrolysis has
been shown to occur
in 84%-87% of women,
with a cure rate of
72% for both obstructive
and irritative
symptoms.
urethral or suprapubic catheters
or intermittent catheterization.
11,12 Women with de
novo urinary urgency and urge
incontinence following sling
surgery and no evidence of urinary
retention may be treated
initially with pelvic floor physiotherapy
and anticholinergic
medications. Alpha-blockers,
anticholinergic drugs, and
muscle relaxants have been
used anecdotally. Some clinicians
report subjective success
with urethral dilation for iatrogenic
obstruction, but the
definitive role of dilation is
unknown at this time. 11,12 The choice of treatment
for urethral obstruction and VD may be
dictated by the severity of symptoms. In mild
cases, patients who can tolerate indwelling
catheters may prefer intermittent catheterization
as an alternative to repeat surgery and a
risk of recurrent SUI. Most authorities recommend
an arbitrary waiting period of 3 months
to ensure adequate time for VD to resolve. 11,12
Most women with VD will begin voiding on
their own within a few days to weeks of intermittent
catheterization. If conservative management
fails after 3 months of treatment, the
patient is probably experiencing prolonged
VD and has a low chance of resolution without
surgical intervention. 11,12
Surgery
If conservative treatment is unsuccessful,
vaginal or retropubic urethrolysis or sling
incision have been shown to achieve good
outcomes. The aim of surgical treatment
should be restoration of normal voiding. It is
debatable whether a urethrolysis or a sling
incision should be the primary operation,
because both procedures have been reported
equally effective. Some clinicians feel that as
urethrolysis involves more extensive surgery,
it is best reserved for patients who fail to benefit
from a sling incision. Ultimately, patient
and surgeon preference and experience may
dictate the type of surgery employed. 4,5,12
Urethrolysis
Urethrolysis may be performed using a retropubic
or a transvaginal approach. The transvaginal
technique is often preferred because
of its ease, decreased morbidity, and rapid
recovery. Indications for retropubic urethrolysis
include primary sling procedures complicated
by bladder perforation or fistula, a
failed transvaginal procedure, or the patient’s
desire to avoid a vaginal incision. 12 Vaginal
urethrolysis may be performed through a
variety of incisions⎯eg, inverted U, midline,
paramedian, or suprameatal. Most commonly,
transvaginal urethrolysis is performed
through a midline or inverted U incision. 13
The main purpose of urethrolysis is to release
the retropubic attachments of the urethra to
the symphysis pubis up to the level of the bladder
neck; this can be achieved using sharp and
blunt dissection techniques. First, a midline
incision is made in the anterior vaginal wall
from the midurethra to 1 or 2 cm proximal to
the bladder neck. Subsequently, the periurethral
fascia is dissected laterally to the pubic
bone and the urethra is dissected from the
undersurface of the pubic bone, thus releasing
all the attachments proximal to the bladder
neck. The dissection is completed when the
urethra is completely mobilized from the symphysis;
this can be confirmed by adequate urethral
rotation/mobility, or by posterior rotation
of the urethra while applying force on a transurethral
instrument or cytoscope. 9,12,14
Significant improvement in voiding efficiency
with urethrolysis has been shown to
occur in 84% to 87% of women, with an overall
cure rate of 72% for both obstructive and irritative
symptoms. 9 The use of a Martius labial
fat-pad graft may provide urethral support
and decrease the risk of recurrent fibrosis, but
can increase morbidity and operative time,
and studies do not demonstrate a significant
improvement in symptom outcomes or lower
SUI rates. 12 It may be possible to perform antiincontinence
surgery (eg, urethral resuspension
or sling) at the time of urethrolysis, but
this may result in persistent urethral obstruction.
Some authors feel that concomitant antiincontinence
surgery should be performed if
urethral support is compromised during urethrolysis,
or if the patient has SUI prior to
urethrolysis. Rates of recurrent SUI after transvaginal
urethrolysis are between 0% and 19%
when urethral resuspension was not performed
concomitantly. 12 Thus, recurrent SUI after urethrolysis
may be corrected at a later time if
necessary, after successful correction of urethral
obstruction. Moreover, many patients
with recurrent SUI may be successfully treated
with office urethral collagen injections. 14
42 The Female Patient | VOL 34 JANUARY 2009 www.femalepatient.com

GRIGORESCU and LAZAROU
Another method of transvaginal urethrolysis
involves a suprameatal approach. 15
Suprameatal urethrolysis aims to limit lateral
dissection of the urethra, and thus
maintain the vesicopelvic ligament intact;
several authors believe this to be integral to
maintaining urinary continence. This urethrolysis
approach uses an inverted U incision
between 3- and 9-o’clock, anterior to the
urethral opening, and a plane is developed
between the urethra and the symphysis
pubis. This technique may be useful in cases
with dense urethral adhesions after prior
unsuccessful urethrolysis, allowing direct
visualization and release of the obstructing
sling. Suprameatal urethrolysis has a documented
success rate of 65% in resolving urinary
retention, with no patients reporting
posturethrolysis SUI. 5,15
Urethrolysis may fail because of persistent
or recurrent urethral obstruction due to urethral
fibrosis and scarring following previous
surgery, detrusor hypocontractility, or
use of the Valsalva maneuver for voiding. If
urethral obstruction persists, a repeat urethrolysis
procedure has been shown to be
effective in resolving obstruction and retention
in 96% of cases. However, urinary
urgency and urge incontinence were fully
relieved in only 12.5% of cases, and SUI
recurred in 18% of patients. 16
Sling Incision
The sling incision is easier to perform than
urethrolysis, results in less morbidity, and
achieves similar outcomes. The sling incision
may be approached through a midline
incision or an inverted U incision in the
anterior vaginal wall. The dissection is continued
in the midline to identify the
obstructing sling. Placing a urethral sound
or urethroscope and elevating the bladder
neck may help to identify a taut sling. The
sling is then carefully freed circumferentially
from the periurethral tissue, avoiding
injury to the urethra and bladder, and it is
incised in the midline. If more urethral
mobility is desired, the lateral edges of the
sling may be freed from the periurethral fascia.
The sling incision procedure is deemed
successful if urethral sagittal mobility is
restored or if good urinary flow is observed
through the urethra from a full bladder while
voiding. 5,12 Success rates for sling incision
range from 84% to 93.5%. Patients who fail to
respond to this procedure may be further
treated with urethrolysis. Rates of recurrent
SUI following sling incision range from 9.4%
to 17%. 8,17 In studies of patients with TVT
slings, sling incision has excellent outcomes,
with return of normal voiding in most
cases. 15,18 Urinary urgency and urge incontinence
were fully relieved in 30% of patients,
and partially relieved in 70%. Stress urinary
incontinence recurred after TVT sling incision
in 6% to 13% of patients. 18,19
PREVENTION OF URETHRAL
OBSTRUCTION
There are no published data
on established techniques
that may prevent urethral
obstruction and consequent
VD after sling procedures.
Nevertheless, final sling
placement must be free of
tension, without any compression
of the urethra or
bladder neck. The sling should
affect urethral compression
only during the Valsalva
maneuver. 20 Some clinicians
believe that sling tension may
be altered during placement
FOCUSPOINT
There are no
published data
on established
techniques that may
prevent urethral
obstruction and
consequent VD
after sling
procedures.
on a case-by-case basis depending on urethral
hypermobility, severity of SUI, and
intrinsic sphincteric deficiency, but no definitive
data have demonstrated that such modifications
increase the efficacy of slings.
Furthermore, the sling may undergo changes
(eg, shrinkage, remodeling) after surgery, and
the intraoperative sling tension and placement
while the patient is in the dorsal lithotomy
position may not reflect its postoperative
characteristics in the upright position, leading
to possible urinary obstruction and VD
despite modifications during surgery. 5
Obstruction after sling surgery is typically
the result of technical factors such as improper
placement, excessive tension, or sling migration,
or may be due to impaired preoperative
voiding function.
CONCLUSION
Sling surgery is a safe and effective treatment
for correcting SUI. Voiding dysfunction
is a rare but well-recognized and
distressing complication of sling surgery
that can be managed successfully through a
number of techniques.
The Female Patient | VOL 34 JANUARY 2009 43

CONTINUING MEDICAL EDUCATION
Managing Voiding Dysfunction After Sling Procedures
REFERENCES
1. Wright EJ, Iselin CE, Carr LK, Webster GD. Pubovaginal
sling using cadaveric allograft fascia for the treatment of
intrinsic sphincteric deficiency. J Urol. 1998;160(3 Pt 1):
759-762.
2. Cross CA, Cespedes RD, McGuire EJ. Our experience with
pubovaginal slings in patients with stress urinary incontinence.
J Urol. 1998;159(4):1195-1198.
3. Nilsson CG, Falconer C, Rezapour M. Seven-year follow-up of
the tension-free vaginal tape procedure for treatment of urinary
incontinence. Obstet Gynecol. 2004;104(6): 1259-1262.
4. Nitti VW, Fleischman N. Voiding dysfunction and urinary
retention. In: Walters MD, Karram MM, eds. Urogynecology
and Reconstructive Pelvic Surgery. Philadelphia, PA: Mosby-
Elsevier, 2007: 390-401.
5. Miller EA, Webster GD. Postoperative complications of sling
surgery. In: Vasavada SP, Appell RA, Sand PK, Raz S, eds.
Female Urology, Urogynecology, and Voiding Dysfunction.
New York, NY:Taylor and Francis, 2005:447-455.
6. Leach GE, Frederirick RW. Stress urinary incontinence
secondary to intrinsic sphincteric deficiency. In: Zimmern
PE, Norton PA, Haab F, Chapple CCR, eds. Vaginal Surgery
for Incontinence and Prolapse. London, UK:Springer;2006:
109-131.
7. Walters MD, Karram MM. Sling procedures for stress
urinary incontinence. In: Walters MD, Karram MM, eds.
Urogynecology and Reconstructive Pelvic Surgery.
Philadelphia, PA: Mosby-Elsevier;2007:196-212.
8. Amundsen CL, Guralnick ML, Webster GD. Variations in
strategy for the treatment of urethral obstruction after a
pubovaginal sling procedure. J Urol. 2000;164(2):434-437.
9. Cross CA, Cespedes RD, English, SF, McGuire EJ. Transvaginal
urethrolysis for urethral obstruction after antiincontinence
surgery. J Urol. 1998;159(4):1199-1201.
10. Powers K, Lazarou G, Greston WM. Delayed urethral erosion
after tension-free vaginal tape. Int Urogynecol J Pelvic
Floor Dysfunct. 2006;17(4):422-425.
11. Karram MM, Segal JL, Vassallo BJ, Kleeman SD. Complication
and untoward effects of the tension-free vaginal tape
procedure. Obstet Gynecol. 2003;101(5 Pt 1):929-932.
12. Nitti VW, Fleischman N. Vaginal approach to postsurgical
bladder outlet obstruction. In: Zimmern PE, Norton PA,
Haab F, Chapple CCR, eds. Vaginal Surgery for Incontinence
and Prolapse. London, UK: Springer; 2006: 209-219.
13. Leach GE, Raz S. Modified Pereyra bladder neck suspension
after previously failed anti-incontinence surgery. Surgical
techniques and results with long-term follow-up.
Urology. 1984;23(4):359-362.
14. Goldman HB, Rackley RR, Appell RA. The efficacy of urethrolysis
without re-suspension for iatrogenic urethral
obstruction. J Urol. 1999;161(1):196-198.
15. Petrou SP, Brown JA, Blaivas JG. Suprameatal transvaginal
urethrolysis. J Urol. 1999;161(4):1268-1271.
16. Scarpero HM, Dmochowski RR, Nitti VW. Repeat urethrolysis
following failed urethrolysis for iatrogenic obstruction.
J Urol. 2003;169(4):1013-1016.
17. Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR. Early
results of pubovaginal sling lysis by midline incision.
Urology. 2002;59(1):47-52.
18. Klutke C, Siegel S, Carlin B, Paszkiewicz E, Kirkemo A, Klutke J.
Urinary retention after tension-free vaginal tape procedure:
incidence and treatment. Urology. 2001;58(5): 697-701.
19. Rardin CR, Rosenblatt PL, Kohli N, Miklos JR, Heit M,
Lucente VR. Release of tension-free vaginal tape for the
treatment of refractory postoperative voiding dysfunction.
Obstet Gynecol. 2002;100(5 Pt 1):898-902.
20. Ghoniem GM, Kapoor DS. Nonautologous sling materials.
Curr Urol Rep. 2001;2(5):357-363.
44 The Female Patient | VOL 34 JANUARY 2009 www.femalepatient.com