1. Managing Obstruction and Voiding Dysfunction After SUI Surgery Victor W. Nitti, MD Professor and Vice Chairman Department of Urology NYU School of Medicine

2. Iatrogenic Obstruction True incidence after incontinence surgery not known –Literature estimates 2.5 - 24% –Obstruction requiring intervention Contemporary sling series 1-3% TVT 1.7 -4.5%

3. Voiding Dysfunction After Incontinence Surgery Dunn et al, Int Urogynecol J 2004; 15:25-31 Medline search 1966-2001 Retrospective collections, case reports or case cohort series Rates of voiding dysfunction: –Burch -4-22% –MMK -5-20% –PVS - 4-10% –Needle Susp. - 5-7% –TVT -2-4%

4. Post Operative Voiding Dysfunction Obstructive –Urinary retention or incomplete emptying –Voiding (obstructive) symptoms –Storage symptoms - frequency, urgency, urge incontinence Non-Obstructive –Storage symptoms With or without detrusor overactivity

5. Etiology Obstruction / Incomplete Emptying –Excessive tension or misplaced sutures or sling –Postoperative cystocele or other prolapse –“Relative” impaired detrusor contractility –Habitual voiding by abdominal straining Storage Symptoms (Frequency/Urgency/UUI) –DO secondary to obstruction –DO without obstruction –“Sensory urgency”

6. Timing of Evaluation / Intervention Depends on procedure Mid urethral synthetic slings early intervention –Some within 1 week ”Classic procedures” –3 months - watchful waiting vs. early intervention –3 - 6 months - formal evaluation and intervention –Decision often based on degree of bother to patient –After 6 months - condition less likely to improve especially for cases of retention

7. Primary Evaluation History* –Preoperative voiding and continence status –Onset of symptoms –Type of procedure performed –Number and type of other procedures Physical Exam* –“Over correction” –Hypermobility –Cystocele, enterocele, rectocele, uterine prolapse * In cases of retention history and physical may be all that is needed

8. Secondary Evaluation Endoscopy –Eroded sutures –Eroded sling –Urethral kink or displacement –Bladder neck mobility - kinking with straining Urodynamics –Videourodynamics

9. Urodynamics Not always helpful in making diagnosis of obstruction after incontinence surgery –Webster & Kreder, 1990 “Urodynamics may fail to diagnose obstruction” –Foster & McGuire, 1993 Urodynamics did not predict outcome –Nitti & Raz, 1994 P det and Q max were not predictive of outcome independently or together. All “acontractile” patients successful

10. Utility of Urodynamics Retention –Can confirm, but not exclude obstruction –May identify learned voiding dysfunction –Information regarding the filling phase Detrusor overactivity / Impaired compliance Irritative symptoms with normal emptying –May rule out obstruction –May provide a specific diagnosis that can be helpful in directing therapy, especially if obstruction can be ruled out

11. Intervention Only absolute selection criteria for urethrolysis should be a temporal relationship between surgery and onset of voiding symptoms Failure to generate a detrusor contraction during urodynamics should not exclude a patient from definitive treatment, e.g. urethrolysis

12. Treatment of Non-Obstructive Voiding Dysfunction When obstruction is ruled out: –Behavioral modification –Antimuscarinics –Neuromodulation –Botulinum toxin

13. Presentation Urinary retention Voiding (obstructive) symptoms Storage (irritative) symptoms - frequency, urgency, urge incontinence Recurrent UTI May have recurrent or persistent SUI with obstruction

14. Conservative Treatment Options For Post Op Obstruction Watchful waiting Intermittent catheterization Indwelling catheter Pharmacotherapy to control associated overactivity Dilation (??)

15. Definitive Treatment Options Midurethral Synthetic Sling Sling incision Sling loosening (early) Urethrolysis Other Procedures Sling Incision (PV sling) Urethrolysis –Transvaginal –Retropubic –Suprameatal (infrapubic) Cut suspension/sling sutures –No published peer-reviewed series

16. Sling Incision Case report described by Ghoneim in 1995 using a vaginal graft interposition Later several authors reported small series of sling incision with and without interposition of vaginal wall

17. Sling Incision Inverted U or midline incision Isolation of sling in the midline Incision of the sling If sling cannot be identified, proceed with formal transvaginal urethrolysis

18. Sling Incision Freeing of the sling from the underlying urethra –May require sharp or blunt dissection No perforation of the endopelvic fascia No freeing of the urethra from the pubic bone Closure of the vaginal wall

20. Sling Incision Results N Type SuccessSUI Nitti, et al 1 19Midline Incision84% 17% Amundsen, et al 2 32Various 94% retention 9% 67% UUI Goldman 3 14Midline Incision93% 21% Amundsen CL, Guralnick ML, Webster GD. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J Urol 2000;164:434–7. 88.Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR. Early results of pubovaginal sling lysis by midline sling incision. Urology 2002;59:47–51; discussion 51–2. 1.Nitti VW, et al. Urology 2002;59:47–52. 2.Amundsen CL, et al. J Urol 2000;164:434–7. 3.Goldman HB. 2003;62:714–8

21. Interactive Question: When and how do you treat catheter dependent retention after an uncomplicated MUSS that you did? 1.After 1 – 2 months perform urodynamics and intervene accordingly 2.Loosen or cut the sling at 1-2 weeks, possibly as an office procedure 3.Cut the sling at 1 month 4.Cut the sling at 2 months 5.Wait at least 3 months before any intervention

22. TVT and Obstruction Klutke, et al Urology 58:697, 2001 –600 patients Multicenter –17 (2.8%) obstructed requiring take down Mean time 64 days (6-228 days) –Simple midline incision –100% success for spontaneous voiding Mean follow up 13 months (12-16) –1 urethral injury –1 (6%) recurrent SUI If within 10 days consider “loosing” sling

23. Obstruction From TVT Critical to identify and cut or loosen sling Urethrolysis without identifying TVT likely to fail In cases of early intervention (up to 14 days) may be able to loosen by pulling down After 10-14 days need to incise as TVT is ingrown with native tissue Chronicallly can become a tight band

24. Technique of Mid Urethral Sling Loosening 1-2 weeks Infiltrate anterior vaginal wall with 1% lidocaine Open vaginal suture line The sling is identified and hooked with a right- angle clamp Spreading of the right angle clamp or downward traction on the tape will usually loosen it (1-2 cm) If the tape is fixed, it can be cut Reapproximate vaginal wall

25. TVT Take Down Results N Type Success Klutke, et al 1 * 17 Midline Incision100% normal emptying Rardin, et al 2 * 23 Midline Incision 100% normal emptying Loosening 30% complete resol. irritative sx 70% partial resol. irritative sx * Recurrent SUI in 6% ** Significant recurrent SUI 13% 26% recurrent SUI, but significantly better than prior to TVT 1.Klutke C, et al. Urology 2001;58:697–701. 2.Rardin CR, et al. Obstet Gynecol 2002;100:898–902.

26. Obstructing TVT at 11 months

27. Obstructing TVT – Retention at 3 Months

28. Case Presentation 48 year old female in urinary retention 4 months prior had POP repair with TVT –“AP repair with SSFL using mesh” After 6 weeks of indwelling catheter was placed on self catheterization 2 months post op had a second procedure where “vaginal scar tissue was removed –No change in symptoms

29. Case Presentation (cont) 3 months post op third procedure where TVT was cut –Op report stated suburethral excision of mesh after TVT was cut –Path report – “fragments and granulation tissue with focal foreign bogy giant cell reaction and chronic inflammation’ –No change in symptoms

30. Case Presentation (cont) Current symptoms –Frequency, urgency, urgency incontinence –Small volume voids –Catheterizes twice per day Additional treatments –Tolterodine for OAB (no help) –Venlafaxin for anxiety Surgeon perplexed

31. Case Presentation (cont) Physical exam –No anterior, apical or posterior prolapse –Urethra not “hypersuspended –Sutures from last surgery intact

32. Permission to void at 203 ml instilled Flouroscopic view near pdetmax

33. Case Presentation: What To Do Next 1.No further treatment 2.Continue intermittent catheterization and add a different antimuscarinic 3.Transvaginal urethrolysis 4.Incise the TVT 5.Take down the prolapse repair

35. Urethrolysis - Anatomy Urethra may be fixed to the pubic bone with dense scar tissue Goal of urethrolysis is to completely free & mobilize urethra

36. Transvaginal Urethrolysis Inverted U incision Lateral dissection above periurethral fascia Endopelvic fascia sharply perforated and retropubic space entered

37. Transvaginal Urethrolysis Sharp and blunt dissection freeing the urethra from the undersurface of the pubic bone Index finger placed between pubic bone and urethra

38. Place penrose drain around the urethra

40. Transvaginal Urethrolysis Optional - Interposition of Martius Flap

41. Retropubic Urethrolysis Mobilization of urethra by sharp dissection –Restore complete mobility to anterior vaginal wall Paravaginal repair Interposition of omentum between urethra and pubic bone

42. Suprameatal Urethrolysis Curved incision above the urethra

43. Suprameatal Urethrolysis Sharp dissection of urethra and bladder neck off pubic bone –Pubourethral, pubovesical “ligaments” incised –Retropubic space entered –Lateral attachments left –? injury to autonomic nerves Martius flap interposition (optional)

44. Urethrolysis Results N Type SuccessSUI Foster & McGuire 48Transvaginal 65% 0 Nitti & Raz 42Transvaginal 71% 0 Cross, et al 39Transvaginal 72% 3% Goldman, et al 32Transvaginal 84% 19% Petrou, et al 32Suprameatal 67% 3% Webster & Kreder 15Retropubic 93% 13% Petrou & Young12Retropubic 83% 18% Carr & Webster 54Mixed 78% 14%

45. Urethrolysis – Predicting Outcomes No consistent predictors of outcome –Only factor predictive of failure was increased PVR (Nitti & Raz) –Higher success in spontaneous voiders vs. those on cath (Foster & McGuire) 74% vs. 54% –No difference for retention vs. irritative symptoms (Petrou, et al) 65% vs. 67%

46. Repeat Incontinence Procedure With Urethrolysis Not routinely necessary after sling incision or transvaginal urethrolysis –Decision can be made at the time of surgery based on operative findings –Recurrent SUI rates 0 - 19% if no resuspension Consider when there is persistent SUI associated with obstruction “Loose” sling preferred

47. Repeat Urethrolysis Scarpero, et al, J Urol, 2003;169:1013-1016 Normal emptying with relief of obstructive symptoms in 22/24 (92%) –PVR < 100 ml 20/22 (91%) catheter dependent patients no longer needed to catheterize 2 non-catheter dependent patients had PVR = 0 P=0.001

48. Repeat Urethrolysis Scarpero, et al, J Urol, 2003;169:1013-1016 Urgency Incontinence 2/16 (12%) resolved 11/16 (69%) improved - required Ach’s 3/15 (19%) no improvement Stress Incontinence 4/22 (18%) de novo SUI 2 had persistent SUI 5 women had bulking and 4 were improved

49. Transvaginal Urethrolysis After Prior Failed Urethrolysis McCreary and Appell Int Urogynecol J, 2007;18:627-633 23 procedures in 21 patients –Mean 1.72 prior procedures 18 patients with obstructive symptoms/findings –13 cured (72%) –9 of 14 catheter dependent patients cured (64%) 17 with irritative symptoms –10 cured (59%) –6 improved (35%)

50. Interstim for Persistent OAB Symptoms After Urethrolysis Starkman et al, Int Urogynecol J 2008; 19:277–282 8 women who failed at least 2 anticholinergics Mean time from urethrolysis to SNM 11.9 months (3-26) 6 responded mean f/u 15.7 months (6-34) –3 OAB symptoms completely resolved PGI-I “very much improved” –3 improved (1-2 UUI episodes/week) PGI-I “much improved”

51. Early Intervention (Mid urethral synthetic sling) YesNo Sling loosening or cutting - office Watchful waiting Failure Transvaginal Sling incision - OR Transvaginal Urethrolysis Repeat Urethrolysis (consider retropubic) Obstructing Sling Algorithm Failure

52. Conclusions Clinically significant obstruction after incontinence surgery is uncommon, but occurs even in the most experienced hands Urethrolysis or sling incision, by a variety of techniques, is successful in restoring emptying and relieving LUTS in the majority of cases