Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethral Obstruction Incidence: % of women with persistent LUTS Symptoms: nothing characteristic – storage 29% – voiding 8% – both 63% B Blaivas & Groutz,, Neurourol & Urodynam 19:553, 2000; Nitti et al, J Urol, 1999

Diagnosis Suspect in: –all women with low Q –with grade 3 & 4 POP –sx onset after incontinence/ prolapse surgery Urodynamics (synchronous pdet / Q) Cystoscopy

Urethral obstruction High detrusor pressure (pdet > 20 cm H 2 0) Low uroflow (Qmax < 12 ml/S)

2 Strss High pressure Low flow

Impaired Detrusor Contractility Weak & or poorly sustained detrusor contraction (pdet < 20 cm H 2 0) Low flow (Qmax < 12 ml/S)

JK Low pressure Low flow

Blaivas - Groutz Nomogram

Diagnosis ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” No specific UDS criteria Obstructed women had: –lower Qmax –higher –higher PVR 23% of 331 women were obstructed Nitti et al, J Urol, 1999

Caveats A pressure flow diagnosis is usually definitive, but An acontractile detrusor or impaired detrusor contractility does not rule out obstruction Persistent voiding dysfunction after incontinence surgery is usually due to obstruction

Etiology Groutz et al, Neurourol Urodyn 19:213,2000; Nitti et al., 1999 Prior surgery % Prolapse 29% Stricture 15% 1 O bladder neck obstruction % DESD 6% Dysfunction voiding % Urethral diverticulum 4%

Urethral Obstruction in women Anatomic Functional

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

Rx Anatomic Urethral Obstruction Intermittent catheterization Surgery - depends on the cau se: –correct prolapse –sling incision / urethrolysis –urethral diverticulectomy –urethroplasty

Rx Functional Urethral Obstruction Primary vesical neck TUI / TUR of vesical neck ? Alpha adrenergic antagonists Neurogenic Intermittent catheterization +/- anticholinergics Botox enterocystoplasty Dysfunctional voiding Bmod / biofeedback / neuromodulation

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

MSCO High pressure Low flow

Rx of Post-op Obstruction First 3 months – monitoring vs intervention May experience improvement Depends on procedure done After 3 months Improvement unlikely Definitive treatment

Mid Urethral Sling Loosening (1-2 weeks) Local anesthesia Open vaginal suture line Hook sling with a right-angle clamp Spread clamp or downward traction on the tape will usually loosen it (1-2 cm) If the tape is fixed, it can be cut

Sling Incision Pull down on Foley and palpate sling Inverted U or midline incision Begin urethral dissection just proximal to sling Isolation of sling in the midline or lateral Incision of the sling Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR, Urology 59:47, 2002

DS

Sling Incision Sling should spring apart If not, dissect it from urethra +/- urethrolysis

TVT Intervention Results N Type Success Klutke, et al* 17 Midline Incision100% normal emptying Rardin, et al** 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

Sling Incision Results N Type Success SUI Klutke, et al Urology 58:697, 2001 Nitti, et al 19Midline Incision84% 17% Amundsen, et al 32Various 94% retention 9% 67% UUI Goldman 14Midline Incision93% 21%

Ureth rolysis Transvaginal Anterior vaginal wall Suprameatal Retropubic

Transvaginal Urethrolysis Inverted U incision Lateral dissection superficial to PCV Endopelvic fascia perforated & retropubic space entered

Transvaginal Urethrolysis Sharp and blunt dissection urethra freed from lateral attachments & undersurface of the pubic bone Index finger placed between pubic bone and urethra +/- Martius flap interposition

Suprameatal Urethrolysis

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%

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

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

Qmax = 36cm H2O Qmax = 8 ml/S

symphysis urethra

Qmax = 54 cm H2O Qmax = 2 ml/S,

symphysis Prolapsed bladder

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

FS = 68 cm H 2 0 Qmax = 5 ml/S Tic

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

= 25 cm H20 Qmax = 0.5 mL/S

Urethral diverticulum Bladder diverticulum Urethra

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

JTJT JT = 75 cm H 2 0 Qmax = 8 ml/S Urethral obstruction

stricture

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

= 100 cm H 2 0 Qmax = 0.5 mL/S

stricture

Surgical Rx of Stricture Urethral dilation Urethrotomy Urethroplasty Ventral flap Dorsal graft

Buccal graft

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

RSN pdetmax = 90 cm H 2 0 Qmax = 7 ml/S

RSN urethra diverticula

Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

2 Strss = 150 cm H20 Qmax = 1 ml/S

Rx Primary Vesical Neck Obstruction Alpha adrenergic blockade Bladder neck incision Bladder neck resection

Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction

CG Involuntary detrusor contraction Involuntary sphincter contraction Vesical neck obstruction

Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

Detrusor contraction Sphincter contraction Low, interrupted flow Obstruction by sphincter

Impaired Detrusor Contractility Low flow Weak or poorly sustained detrusor contraction Pressure flow criteria: –Qmax < 12 ml/s < 20 cm H2O Groutz et al, Neurourol Urodyn 19:213,2000

amb pdetmax = 10 cm H 2 0) Qmax = 8 ml/S

Impaired Detrusor Contractility: Etiology Neurogenic –Thoracic, lumbar & sacral lesions –Diabetes mellitus Myogenic –Primary / idiopathc –Urethral obstruction –Bladder overdistension Urethral obstruction Post-surgical –Ischemia Groutz et al, Neurourol Urodyn 19:213,2000

Impaired Detrusor Contractility: Treatment Observation Double voiding Timed voiding Intermittent catheterization ? Medications –Cholinergic agonists –Alpha adrenergic antagonists

Conclusion Urethral obstuction not uncommon Prevalence: % of pts with LUTS Symptoms – non-specific –irritative 29% –obstructive 8% –both 63% Diagnosis based on p/Q studies Rx based on underlying cause usually effective for both voiding and OAB sx