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  • Review Article
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Iatrogenic obstruction after sling surgery

Nature Reviews Urology volume 9, pages 429–434 (2012)Cite this article

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Abstract

Sling surgery has supplanted other anti-incontinence procedures as the treatment of choice for stress urinary incontinence. Iatrogenic obstruction after sling surgery is increasingly reported as the procedure becomes more and more popular. The rate of retention (defined as catheter-dependency for at least 28 days) has been estimated at 1–10%. Iatrogenic obstruction after sling surgery has a variable presentation and can include urinary urgency, urgency incontinence, hesitancy, straining to void, weak urinary stream, nocturia, incomplete emptying, frequency, dysuria or urinary tract infections. The evaluation and diagnosis rely upon a thorough patient history, physical examination, a urine flow test and postvoid residual volume. Cystoscopy and pressure-flow studies can also be considered. The single most important factor in the diagnosis of sling-related obstruction or voiding dysfunction is the temporal relationship between the sling procedure and onset of symptoms. Transient urinary retention can be managed with indwelling or intermittent catheter drainage. For those patients with moderate or symptomatic retention, surgical options for treatment include sling loosening, sling incision, sling excision, and urethrolysis.

Key Points

  • The incidence of iatrogenic sling obstruction is variable and dependent on the definition of obstruction used

  • The rate of retention, defined as catheter dependency for at least 28 days, has been estimated at 1–10%

  • The single most important factor in the diagnosis of sling-related obstruction or voiding dysfunction is the temporal relationship between surgery and the onset of symptoms

  • Iatrogenic obstruction after sling surgery has a variable presentation and can include urinary urgency, urgency incontinence, hesitancy, straining to void, weak urinary stream, nocturia, incomplete emptying, frequency, dysuria or UTI

  • The evaluation of patients with iatrogenic obstruction should include a history, a physical exam, a urine flow test and a postvoid residual volume. The clinician might also consider cystoscopy and pressure-flow studies

  • For patients with significant or symptomatic retention, surgical options for treatment include sling loosening, sling incision, sling excision, and urethrolysis

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References

  1. Luber, K. M. The definition, prevalence, and risk factors for stress urinary incontinence. Rev. Urol. 6 (Suppl. 3), S3–S9 (2004).

    PubMed  PubMed Central  Google Scholar 

  2. Haylen, B. T. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int. Urogynecol. J. 21, 5–26 (2010).

    Article  PubMed  Google Scholar 

  3. Appell, R. A. et al. Guideline for the surgical management of female SUI 2009 Update. American Urological Association [online], (2009).

    Google Scholar 

  4. Meschia, M. et al. Tension-free vaginal tape: analysis of outcomes and complications in 404 stress incontinence women. Int. Urogynecol. J. Pelvic Floor Dysfunct. 12 (Suppl. 2), S24–S27 (2001).

    Article  PubMed  Google Scholar 

  5. Gateau, T. et al. Clinical and urodynamic repercussions after TVT procedure and how to diminish patient complaints. Eur. Urol. 44, 372–376 (2003).

    Article  CAS  PubMed  Google Scholar 

  6. Sander, P., Møller, L. M., Rudnicki, P. M. & Lose, G. Does the tension-free vaginal tape procedure affect the voiding phase? Pressure flow studies before and 1 year after surgery. BJU Int. 89, 694–698 (2002).

    Article  PubMed  Google Scholar 

  7. Kraus, S. R. et al. Changes in urodynamic measures two years after Burch colposuspension or autologous sling surgery. Urology 78, 1263–1268 (2011).

    Article  PubMed  Google Scholar 

  8. Lemack, G. E. et al. Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling. J. Urol. 180, 2076–2080 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Iglesia, C. B., Shott, S., Fenner, D. E. & Brubaker, L. Effect of preoperative voiding mechanism on success rate of autologous rectus fascia suburethral sling procedure. Obstet. Gynecol. 91, 577–581 (1998).

    CAS  PubMed  Google Scholar 

  10. Kawashima, H. et al. The importance of studying pressure-flow for predicting postoperative voiding difficulties in women with stress urinary incontinence: a preliminary study that correlates low Pdet x Qave with postoperative residual urine. Urol. Res. 32, 84–88 (2004).

    Article  PubMed  Google Scholar 

  11. Hong, B., Park, S., Kim, H. S. & Choo, M. S. Factors predictive of urinary retention after a tension free vaginal tape procedure for stress urinary incontinence. J. Urol. 170, 852–856 (2003).

    Article  PubMed  Google Scholar 

  12. Weinberger, M. W. & Ostergard, D. R. Postoperative catheterization, urinary retention, and permanent voiding dysfunction after polytetrafluorethylene suburethral sling placement. Obstet. Gynecol. 87, 50–54 (1996).

    Article  CAS  PubMed  Google Scholar 

  13. Richter, H. E. et al. Retropubic versus transobturator midurethral slings for stress incontinence. N. Engl. J. Med. 362, 2066–2076 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Anger, J. T., Litwin, M. S., Wang, Q., Pashos, C. L. & Rodríguez, L. V. The effect of age on outcomes of sling surgery for urinary incontinence. Am. Geriatr. Soc. 55, 1927–1931 (2007).

    Article  Google Scholar 

  15. Sarnelli, G., D'Urso, L. & Muto, G. Tension-free vaginal tape (TVT) for the treatment of female stress urinary incontinence (SUI): evaluating perineal ultrasound (PU) findings in postoperative voiding obstructive complaints. Arch. Ital. Urol. Androl. 80, 92–94 (2008).

    PubMed  Google Scholar 

  16. Velemir, L., Amblard, J., Jacquetin, B. & Fatton, B. Urethral erosion after suburethral synthetic slings: risk factors, diagnosis, and functional outcome after surgical management. Int. Urogynecol. J. Pelvic Floor Dysfunct. 19, 999–1006 (2008).

    Article  CAS  PubMed  Google Scholar 

  17. Kuo, H. C. Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction. Urology 66, 1005–1009 (2005).

    Article  PubMed  Google Scholar 

  18. Sweeney, D. D. & Leng, W. W. Treatment of postoperative voiding dysfunction following incontinence surgery. Curr. Urol. Rep. 6, 365–370 (2005).

    Article  PubMed  Google Scholar 

  19. Farrar, D. J. et al. A urodynamic view of bladder outflow obstruction in the female: factors influencing the results of treatment. Br. J. Urol. 47, 815–822 (1975).

    Article  CAS  PubMed  Google Scholar 

  20. Webster, G. D. & Kreder, K. J. Voiding dysfunction following cystourethropexy: its evaluation and management. J. Urol. 144, 670–673 (1990).

    Article  CAS  PubMed  Google Scholar 

  21. Foster, H. E. & McGuire, E. J. Management of urethral obstruction with transvaginal urethrolysis. J. Urol. 150, 1448–1451 (1993).

    Article  CAS  PubMed  Google Scholar 

  22. Klutke, C. et al. Urinary retention after tension-free vaginal tape procedure: incidence and treatment. Urology 58, 697–701 (2001).

    Article  CAS  PubMed  Google Scholar 

  23. Nguyen, J. N. Tape mobilization for urinary retention after tension-free vaginal tape procedures. Urology 66, 523–526 (2005).

    Article  PubMed  Google Scholar 

  24. Gamé, X. et al. Treatment of bladder outlet obstruction secondary to suburethral tape by section of the tape. Prog. Urol. 16, 67–71 (2006).

    PubMed  Google Scholar 

  25. Laurikainen, E. & Kiillholma, P. A nationwide analysis of transvaginal tape release for urinary retention after tension-free vaginal tape procedure. Int. Urogynecol. J. 17, 111–119 (2006).

    Article  CAS  Google Scholar 

  26. Hong, B., Park, S., Kim, H. S. & Choo, M. S. Factors predictive of urinary retention after a tension free vaginal tape procedure for stress urinary incontinence. J. Urol. 170, 852–856 (2003).

    Article  PubMed  Google Scholar 

  27. Car, L. K. & Webster, G. D. Voiding dysfunction following incontinence surgery: diagnosis and treatment with retropubic or vaginal urethrolysis. J. Urol. 157, 821–823 (1997).

    Article  Google Scholar 

  28. Leng, W. W., Davies, B. J., Tarin, T., Sweeney, D. D. & Chancellor, M. B. Delayed treatment of bladder outlet obstruction after sling surgery: association with irreversible bladder dysfunction. J. Urol. 172, 1379–1381 (2004).

    Article  PubMed  Google Scholar 

  29. Rutner, A. B., Levine, S. R. & Schmaelzle, J. F. Processed porcine small intestine submucosa as a graft material for pubovaginal slings: durability and results. Urology 62, 805–809 (2003).

    Article  PubMed  Google Scholar 

  30. Abdel-Fattah, M., Barrington, J. W. & Arunkalaivanan, A. S. Pelvicol pubovaginal sling versus tension-free vaginal tape for treatment of urodynamics stress incontinence: a prospective randomized three year follow-up study. Eur. Urol. 46, 629–635 (2004).

    Article  CAS  PubMed  Google Scholar 

  31. Amundsen, C. L., Visco, A. G., Ruiz, H. & Webster, G. D. Outcome of 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. Urology 56 (6 Suppl. 1), 2–8 (2000).

    Article  CAS  PubMed  Google Scholar 

  32. Brown, S. L. & Govier, F. E. Cadaveric versus autologous fascia lata for the pubovaginal sling: surgical outcome and patient satisfaction. J. Urol. 164, 1633–1637 (2000).

    Article  CAS  PubMed  Google Scholar 

  33. Walsh, I. K., Nambirajan, T., Donellan, S. M., Mahendra, V. & Stone, A. R. Cadaveric fascia lata pubovaginal slings: early results on safety, efficacy, and patient satisfaction. BJU Int. 90, 415–419 (2002).

    Article  CAS  PubMed  Google Scholar 

  34. Carbone, J. M., Kavaler, E., Hu, J. C. & Raz, S. Pubovaginal sling using cadaveric fascia and bone anchors: disappointing early results. J. Urol. 165, 1605–1611 (2001).

    Article  CAS  PubMed  Google Scholar 

  35. Carey, J. M. & Leach, G. E. Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients. Urology 63, 665–670 (2004).

    Article  PubMed  Google Scholar 

  36. Owens, D. C. & Winters, J. C. Pubovaginal sling using duraderm graft. Neurourol. Urodyn. 23, 115–118 (2004).

    Article  PubMed  Google Scholar 

  37. Crivellaro, S., Smith, J. J., Kocjancic, E. & Bresette, J. F. Transvaginal sling using acellular human dermal allograft. J. Urol. 172, 1374–1378 (2004).

    Article  CAS  PubMed  Google Scholar 

  38. Beck, R. P., McCormick, S. & Nordstrom, L. The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine. Obstet. Gynecol. 72, 699–703 (1988).

    CAS  PubMed  Google Scholar 

  39. Chaikin, D. C., Rosenthal, J. & Blaivas, J. G. Pubovaginal fascial sling for all types of stress urinary incontinence. J. Urol. 160, 1312–1316 (1998).

    Article  CAS  PubMed  Google Scholar 

  40. Chou, E. C., Flisser, A. J., Panagopoulos, G. & Blaivas, J. G. Effective treatment for mixed urinary incontinence with pubovaginal sling. J. Urol. 170, 494–197 (2003).

    Article  PubMed  Google Scholar 

  41. Morgan, T. O. Jr, Westney, O. L. & McGuire, E. J. Pubovaginal sling: 4-year outcome analysis and quality of life assessment. J. Urol. 163, 1845–1848 (2000).

    Article  PubMed  Google Scholar 

  42. Hassouna, M. E. & Ghoniem, G. M. Long term outcome and quality of life after modified pubovaginal sling for intrinsic sphincter deficiency. Urology 53, 287–291 (1999).

    Article  CAS  PubMed  Google Scholar 

  43. Mustafa, M. & Wadie, B. S. In situ anterior vaginal wall sling for treatment of stress urinary incontinence: extended application and further experience. Urol. J. 6, 35–39 (2009).

    PubMed  Google Scholar 

  44. Kaplan, S. A. et al. Prospective analysis of 373 consecutive women with stress urinary incontinence treated with a vaginal wall sling. J. Urol. 164, 1623–1327 (2006).

    Article  Google Scholar 

  45. Brubaker, L. et al. Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study. Am. J. Obstet. Gynecol. 205, 498.e1–e6 (2011).

    Article  Google Scholar 

  46. Rardin, C. R. et al. Release of tension free vaginal tape for the treatment of refractory postoperative voiding dysfunction. Obstet. Gynecol. 100, 898–902 (2002).

    CAS  PubMed  Google Scholar 

  47. Glavind, K. & Glavind, E. Treatment of prolonged voiding dysfunction after tension free vaginal tape procedure. Acta Obstet. Gynecol. Scand. 86, 357–360 (2007).

    Article  PubMed  Google Scholar 

  48. Oliveira, R. et al. Single incision sling system as primary treatment of female urinary incontinence: prospective 12 months data from a single institution. BJU Int. 108, 1616–1621 (2011).

    Article  PubMed  Google Scholar 

  49. Moore, R. D., Mitchell, G. K. & Miklos, J. R. Single center retrospective study of the technique, safety, and 12-month efficacy of the MiniArc Single-Incision Sling: a new minimally invasive procedure for treatment of female SUI. Surg. Technol. Int. 18, 175–181 (2009).

    CAS  PubMed  Google Scholar 

  50. Neuman, M. Perioperative complications and early follow-up with 100 TVT-SECUR procedures. J. Minim. Invasive Gynecol. 15, 480–484 (2008).

    Article  PubMed  Google Scholar 

  51. Thiel, D. D., Pettit, P. D., McClellan, W. T. & Petrou, S. P. Long-term continence rates after simple sling incision for relief of urinary retention following fascia lata pubovaginal slings. J. Urol. 174, 1878–1881 (2005).

    Article  PubMed  Google Scholar 

  52. Goldman, H. B. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 62, 714–718 (2003).

    Article  PubMed  Google Scholar 

  53. Nitti, V. W., Carlson, K. V., Blaivas, J. G. & Dmochowski, R. R. Early results of pubovaginal sling lysis by midline sling incision. Urology 59, 47–51 (2002).

    Article  PubMed  Google Scholar 

  54. Kusuda, L. Simple release of pubovaginal sling. Urology 57, 358–359 (2001).

    Article  CAS  PubMed  Google Scholar 

  55. Amundsen, C. L., Guralnick, M. L. & Webster, G. D. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J. Urol. 164, 434–437 (2000).

    Article  CAS  PubMed  Google Scholar 

  56. Petrou, S. P., Brown, J. A. & Blaivas, J. G. Suprameatal transvaginal urethrolysis. J. Urol. 161, 1268–1271 (1999).

    Article  CAS  PubMed  Google Scholar 

  57. Goldman, H. B., Rackley, R. R. & Appell, R. A. The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction. J. Urol. 161, 196–198 (1999).

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Virginia Mason Medical Center, Section of Urology and Renal Transplantation, C7-URO, 1100 9th Avenue, Seattle, 98101, WA, USA

    Bhavin N. Patel & Kathleen C. Kobashi

  2. St Elizabeth's Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, 02111, MA, USA

    David Staskin

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  2. Kathleen C. Kobashi
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  3. David Staskin
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B. Patel researched data for the article. B. Patel and K. Kobashi wrote the article. B. Patel, K. Kobashi and D. Staskin made substantial contribution to discussion of content for the article, and reviewing the manuscript before submission.

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Correspondence to Bhavin N. Patel.

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Patel, B., Kobashi, K. & Staskin, D. Iatrogenic obstruction after sling surgery. Nat Rev Urol 9, 429–434 (2012). https://doi.org/10.1038/nrurol.2012.110

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