Risk factors

ORIGINALARTICLE

Riskfactorsassociatedwithvoidingdysfunctionafteranti-incontinencesurgery

Sue-MinChung&Yeo-JungMoon&Myung-JaeJeon&Sei-KwangKim&Sang-WookBai

Received:12March2010/Accepted:16July2010/Publishedonline:4August2010#TheInternationalUrogynecologicalAssociation2010

Abstract

IntroductionandhypothesisTheaimofthisstudyistoinvestigatetheriskfactorsofvoidingdysfunctionoccur-ringwithin1monthaftersurgicaltreatmentofurinaryincontinence.

MethodsMedicalrecordsof903womenwhounderwentanti-incontinencesurgeryatYonseiMedicalHealthSystemfromJanuary1999toApril2007werereviewed.Thepatientdemographics,urodynamicparameters,pelvicorganprolapsestage,surgicalprocedures,andconcomitantsurgerywereretrospectivelyevaluated.Postoperativevoid-ingdysfunctionwasdefinedaspost-voidresidualurinemeasuringgreaterthan100ccattwoormoresuccessivetrials.

ResultsAge,menopausalstatus,maximumflowrate,averageflowrate,post-voidresidual,anti-incontinencesurgerytype,stageofpelvicorganprolapse,andconcom-itantprolapsesurgerywereassociatedpredictorsofvoiding

S.-M.Chung:Y.-J.Moon:S.-K.KimDepartmentofObstetricsandGynecology,YonseiUniversityHealthSystem,Seoul,Korea

M.-J.Jeon

DepartmentofObstetricsandGynecology,SeoulNationalUniversity,Seoul,Korea

S.-W.Bai

DepartmentofUrogynecology,YonseiUniversityHealthSystem,Seoul,Korea

S.-W.Bai(*)

DepartmentofObstetricsandGynecology,YonseiUniversityCollegeofMedicine,

134Shinchon-dong,Seodaemoon-gu,Seoul120-752,Koreae-mail:swbai@yuhs.ac

dysfunctionafteranti-incontinencesurgery.Inmultivariateanalysis,concomitantanteriorcolporrhaphy(OR2.4;95%CI1.38–4.11)wastheonlyindependentriskfactor.

ConclusionsThemostimportantriskfactorassociatedwithvoidingdysfunctionwasconcomitantanteriorcolporrhaphy.KeywordsAnti-incontinencesurgery.Voiding

dysfunction.Stressurinaryincontinence.Pelvicorganprolapse.Colporrhaphy

Introduction

Stressurinaryincontinenceexperiencedbyapproximatelyonethirdofwomencaneffectivelybetreatedbysurgicalmethod,whichprovidesalong-termcureinasignificantnumberofpatients[1,2].Untilnow,morethan200surgicaltechniqueshavebeendemonstratedasthetreat-mentforstressurinaryincontinence,andthemostcom-monlyusedproceduresincludeBurchcolposuspension,pubovaginalsling,tension-freevaginaltape(TVT),andtransobturatortape(TOT)[2].

Aftertheanti-incontinencesurgery,however,voidingdysfunction,aknowncomplicationresultingfromover-correctionoftheurethrasecondarytohyperelevationofthebladderneck,mayfollow.Accordingtopreviousliterature,postoperativevoidingdifficultiesandurinaryretentionhavebeenreportedtooccurinupto20%ofthepatientsafterBurchcolposuspension,10%afterpubovaginalsling,20%afterTVT,and20%afterTOT[2–12].InananalysiscomparingTVTandTOT,bladderinjuryandvoidingdifficultywerefoundtobelessfortheobturatorroute[4–7].Mostcasesofmildpostoperativevoidingdysfunctiontendtoresolvewithexpectantmanagement,whilesymp-tomsthatpersistforlongerthanamonthrarelyresolvespontaneously[3].

1506Riskfactorsrelatedtopostoperativevoidingdysfunctionincludingdemographicfactors,voidingparameters,andanatomicalfactorshavebeenidentifiedinanumberofpublications.However,althoughthesymptomsofpostoper-ativevoidingdysfunctionaggravatethepatients’anxietyandreducesatisfactionaftertreatment,therehasn’tbeenenoughresearchonthesubject.Thepurposeofthisstudyistoinvestigatetheriskfactorsassociatedwithvoidingdysfunc-tionoccurringwithin1monthaftersurgicaltreatmentofstressurinaryincontinence.

Materialsandmethods

BetweenJanuary1999andApril2007,atotalof903womenwhoreceivedsurgicaltreatmentforstressurinaryinconti-nenceatYonseiUniversityHealthSystemwereeligibleforthestudy,andthemedicalrecordswereretrospectivelyreviewed.Allpatientsgaveinformedconsent,andtheirhistorieswereobtainedthroughstandardinterviewsandphysicalexamination,includingpreoperativeevaluationsonprolapsebythePOP-Qsystem[13]andmultichannelurodynamicstudy.ThisstudywasapprovedbytheYonseiUniversityHealthSysteminstitutionalreviewboard.

Thestandardinterviewincludedpatientinformationonage,parity,bodymassindex(BMI),previousanti-incontinencesurgeryhistory,priorpelvicreconstructivesurgery,familyhistory(inmotherorsister),menopause,andhormonereplacementtherapystatus.Urodynamicstudies(Dantec-5000;Copenhagen,Denmark)includeduroflowme-try,multichannelcystometry,Valsalvaleakpointpressure,andurethralpressureprofilometry.Thepatientswereenrolledafterhavingurodynamicdiagnosisofstressurinaryinconti-nence.Womenwithassociatedpelvicorganprolapsewereallowedinthestudy.

ThesurgicalprocedurescarriedoutonpatientswithstressurinaryincontinencewereBurchcolposuspension,pubovagi-nalsling,TVT(polypropylene;Gynecare,EthiconInc.,Somerville,NJ),andTOT(polypropylene;Iris,DowmedicsCo.Ltd.,Wonju,Korea),allofwhichwereperformedbyasinglesurgeon.Atthebeginningofthisstudy,Burchcolposuspensionandpubovaginalslingwerealreadybeingperformed,whereasTVTandTOT,theminimallyinvasiveslings,wereintroducedin2000and2004,respectively.

TheprocedureswereperformedasdescribedbyCrossetal.[14],Ulmstenetal.[15],andDelorme[16]underregionalorgeneralanesthesia.InBurchcolposuspension,thebladderneckandproximalurethraweresupportedbyasuspensionoftheparavaginaltissuestowardstheipsilateralileopectinealligamentsonthepelvicsidewalls,andpubovaginalslingwasperformedbythefixationoftheslingaroundthebladderneckusingsyntheticmaterialssuchasnylonorprolene.

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Wedefinedvoidingdysfunctionaspost-voidresidualurinemeasuringgreaterthan100ccattwoormorerepeatedtrialsofvoidingafterremovalofFoleycatheterwhichtookplaceonthefirstpostoperativedayofanti-incontinencesurgeryandonthefifthdayofprolapsesurgery.

Univariateanalysisofthepotentialriskfactorswasperformed.Thevariablesconsideredinrelationtopostoper-ativevoidingdysfunctionwereage,parity,bodymassindex(BMI),menopausestatus,hormonetherapy,preoperativeuroflowmetryfindings(maximumflowrateandaverageflowrate),incontinencesurgerytype,concurrentpelvicorganprolapsestage,andconcomitantsurgerysuchashysterectomyorprolapsesurgery.Theresultsfromtheunivariateanalysiswerethenincludedinthemultivariatelogisticregression(forwardsstepwisetechnique)todeterminetheindependentriskfactorsandtheiroddsratio.

Statisticalanalysisofthedatawasperformedusingstudent’sttest,chi-squaretest,Fisher’sexacttest,andmultivariatelogisticregressionanalysis.Apvaluelessthan0.05wasconsideredstatisticallysignificant.

Results

Ofthe903enrolledpatientswithstressurinaryincontinencewhoreceivedthesurgicaltreatments,326(36%)patientsshowedpostoperativevoidingdysfunctionwithin1month,and577(%)patientshadnovoidingdifficulties.Thepatientsinvoidingdysfunctiongroupeventuallyresolvedwithconservativemanagementandreturnedtonormalinaboutaweekor10daysatmostbeforedischarge.ThetypesofincontinencesurgeryweperformedincludedBurchcolposus-pension(n=284),pubovaginalsling(n=61),TVT(n=297),andTOT(n=260).Thepatientcharacteristicsandpossiblepredictivefactorswereanalyzedinpatientswithandwithoutvoidingdysfunction.

Table1listsclinicalcharacteristicsofthepatientsinthetwogroups.Thepatients’meanagewas58invoidingdys-functiongroup,3yearsolderthaninnormalvoidinggroup(p<0.001).Postmenopausalwomenwere251(76.8%)fromthegroupwithvoidingdysfunction,significantlyhigherthanwomeninthegroupwithoutvoidingdysfunction(65.9%;p=0.001).Theuroflowmetryfindingsincludingmaximumflowrate(24.90ml/s±22.40vs.28.49ml/s±20.76),averageflowrate(11.95ml/s±6.48vs.14.06ml/s±6.77),andpreoperativepost-voidresidual(27.11ml±61.84vs.18.06ml±38.07)werealsoidentifiedassignificantriskfactors.Asforanti-incontinencesurgery,womenwhoreceivedpubovaginalslingandTVTshowedmorepatientswithvoidingdysfunctioncomparedtothosewhoreceivedBurchcolposuspensionorTOT.Inpatientswithstressurinaryincontinenceandconcurrentpelvicorganprolapse,46.1%of

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Table1PatientcharacteristicsaccordingtosurgicaloutcomeVariables

Age(years)Parity

BMI(kg/m2)

Menopause,n(%)

Hormonetherapy,n(%)UrodynamicparametersMaximumflowrate(ml/s)Averageflowrate(ml/s)Residualvolume(ml)

Incontinencesurgerytype,n(%)BurchcolposuspensionPubovaginalslingTVTTOT

POPstage,n(%)0orIIIIIIIV

Concomitantsurgery,n(%)HysterectomyProlapsesurgeryAnteriorPosteriorApical

Novoidingdysfunction(n=577)55.2±10.43.0±1.524.5±2.9380(65.9)80(20.7)28.5±20.814.1±6.818.1±38.1205(35.5)30(5.2)174(30.2)168(29.1)266(46.1)148(25.6)106(18.4)57(9.9)151(30.3)186(32.2)288(49.9)141(24.4)

Voidingdysfunction(n=326)58.6±10.23.4±1.524.8±11.1251(76.8)51(20.3)24.9±22.412.0±6.527.1±61.879(24.3)31(9.5)123(37.8)92(28.3)

1507

pvalue<0.0010.4070.5590.0010.9010.049<0.0010.049<0.001

<0.001

97949837(29.8)(28.8)(30.1)(11.3)

0.814<0.001<0.0010.002

87(31.1)184(56.3)211(.5)112(34.3)

BMIbodymassindex,POPpelvicorganprolapse,TVTtension-freevaginaltape,TOTtransobturatortape

patientswithoutvoidingdysfunctionhadprolapsestage0orIcomparedto29.8%ofpatientswithvoidingdysfunction.Asthedegreeofprolapseincreased,higherstagesconsistedofmorepatientswithvoidingdysfunction.

Prolapsesurgerywasperformedseparatelybythreedifferentcompartments:anterior,posterior,andapical.Thesurgicaloutcomeofthethreetypesofprolapsesurgerywasthatinalltypes,therewerealargernumberofpatientswithpostoperativevoidingdysfunctionthanthosewithout.Thetwogroupswerecomparablewithrespecttomedianparity,BMI,hormonetherapystatus,andconcomitanthysterectomy.

Table2showsthemultivariateanalysisresultshowingthatconcomitantanteriorcolporrhaphy(OR2.4;95%CI1.38–4.11)wastheonlyindependentriskfactorofpostoperativevoidingdysfunction.Duringanteriorcolpor-rhaphy,thevaginalmucosabelowtheurethrawasdissect-ed,andsutureswereplacedintheperiurethraltissueandpubocervicalfasciatoelevateandsupportthebladderneckandproximalurethra.

Discussion

InBurchcolposuspension,atransabdominaltechniquedescribedbyJohnBurchin1961,thebladderneckandproximalurethraaresupportedbyasuspensionoftheparavaginaltissuestowardstheipsilateralileopectinealliga-mentsonthepelvicsidewalls[2].Asfixationmechanismforpubovaginalsling,firstdescribedin1907andnumerousmodificationshavingbeenmadesince,someusedmuscle(suchaspyramidalisorgracilis)orautologousfascia(rectussheathorfascialata),andothersusedsyntheticmaterialssuchasnylonormarlex[2].Forthepastfewyears,thesetwoprocedureshadbeenconsideredasthegoldstandardsforthesurgicaltreatmentofstressurinaryincontinence.Butrecently,anumberofstudieshaveshownthatTVT,introducedin1995,wassignificantlymoreeffectivewithappreciablylowerperioperativemorbidity[17,18].Throughasmalllongitudinalvaginalincision,atapeisinsertedandleftwithouttensionatthelevelofthemid-urethrabytwo-componentneedleinstrumentcrossingthespaceofRetzius

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Table2MultivariateanalysisRiskfactors

Oddsratio95%CIAge(years)1.0210.996–1.047Menopause0.9920.565–1.742Qmax(ml/s)0.9990.988–1.010Qavr(ml/s)0.9680.932–1.004PVR(ml)

1.0030.999–1.007IncontinencesurgerytypeBurchcolposuspension1.5500.913–2.632Pubovaginalsling2.2780.919–5.6TVT

1.1090.684–1.798

TOT(reference)1.000POPstage

0orI(reference)1.000II0.9480.4–1.978III1.1420.445–2.935IV

0.735

0.231–2.342

ConcomitantsurgeryProlapsesurgeryAnterior2.3781.375–4.111Posterior0.9690.506–1.8Apical

0.8060.398–1.632

Qmaxresidual,maximumPOPpelvicfloworganrate,Qavrprolapse,averageTVTflowtension-freerate,PVRvaginalpost-voidtape,TOTtransobturatortape

towardstheanteriorabdominalwall[2].Thereafter,theTOTwasdevelopedin2001byDelormeasanewminimallyinvasivesurgicalmethodtoavoidtheblindpassageoftheneedleintheretropubicspace[14].Theriskofabladderinjuryhasbeenreducedwiththisperinealtechnique.

Stressurinaryincontinenceis,however,frequentlyassoci-atedwithpelvicorganprolapse.IthasbeenreportedinastudybyBaietal.that63.3%ofpatientswithstressurinaryincontinencehadcoexistingpelvicorganprolapse,mostoftenoftheanteriorwall,and62.7%ofpatientswithpelvicorganprolapsehadcoexistingstressurinaryincontinence[19].Incasesofperformingcombinedproceduresinsuchpatients,oneproceduremayhaveeitherpositiveornegativeinfluenceontheotherasforthetreatmentoutcomeandpostoperativecomplications.Jeonetal.,inevaluatingtheoutcomeofTOTaffectedbyconcomitantpelvicreconstructivesurgery,hadresultedthatimmediatepostoperativevoidingdysfunctionwasmorefrequentinthecombinedsurgerygroup[20].Loetal.reportedthatTVTwithconcurrentprolapsesurgeryiscommonlyfollowedbytransienturinaryretention[21].Inthisstudy,wefoundthatconcomitantprolapsesurgery,especiallyanteriorcolporrhaphy,wasanindepen-dentriskfactorofpostoperativevoidingdysfunctionafter

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undergoingsurgicaltreatmentofstressurinaryinconti-nence.ThelimitedmobilityofthevaginalwallafteranteriorprolapsesurgeryorpossiblenerveinjurycouldbeconsideredascausativefactorsforfailedordelayedpostoperativevoidingreferredtoanarticlebyMutoneetal.whohadreportedsimilarresultstooursconcludingthatoldageandhistoryofincontinenceorprolapsesurgerywereassociatedwithdelayedreturnofnormalvoidingfunction.However,theymaynotbereliablepredictorssincethetypesofpreviousprocedureswerenotdescribed[22].

Inreviewofotherpreviousarticles,severalfactorshavebeencitedaspredictiveofpostoperativeurinaryretention.LaSalaetal.stated2.3%incidenceofpostoperativevoidingdysfunctionafterTVTplacement,whichwasaffectedbyconcomitantanteriorcolporrhaphy[23].Someauthorsimplicatepoordetrusorfunctionasariskfactorforurinaryretentionaftersurgicaltreatment,andsomeresearchersregardpreoperativebladdersymptoms,increasedpost-voidresidualvolume,lowvoidingpeakflowrate,ornormaltoelevatedmaximumvoidingvesicalpressureaspredictiveofpoorpostoperativebladderfunction[24–27].

Onthecontrary,Weinbergeretal.provednosignificantrelationshipbetweenpreoperativeuroflowmetryfindingsandthepostoperativevoidingdysfunction[28].Also,Sokoletal.foundnodifferenceinvoidingfunctionbetweenpatientswhohadTVTaloneorwithconcurrentprolapsesurgeryincontrasttopreviousstudiesandoursalsoshowedhigherratesofurinaryretentionaftercombinedprocedures[29].

Kleemanetal.describedastandardizedpostoperativevoidingtrialtotestpatientshavingundergonesurgeryforstressurinaryincontinenceintheirstudy,whichconsistedoffillingthebladderwith300cc,followedbyaspontaneousvoid[30].Inourstudy,wehadpatientstestedforvoidingdysfunctionbymeasuringgreaterthan100ccofpost-voidresidualvolumeonmorethantwoconsecutivevoidingtrialsaftercatheterremoval.Thelackofstandard-izeddefinitionsanddiagnosticcriteriaofvoidingdysfunc-tionisoneofthelimitationsofthepresentstudy.Also,thereisnopressure–flowdatawhichareimportantwhenaddressingvoidingdysfunction.Morethanhalfofdataweremissinginourretrospectivereview,andwecouldnotincludethedatainthestudy.

Inconclusionofthisstudy,theconcurrentsurgeryhadsignificantinfluenceontheoutcomeratherthanthetypeoftheincontinencesurgery.Thepatientsundergoinganti-incontinencesurgeryandanteriorcolporrhaphyatthesametimeweremorelikelytoexperiencepostoperativevoidingdysfunctionthanthoseundergoingconcurrentapicalorposteriorcolporrhaphy,orthosewhodidnotreceiveconcomitantprolapsesurgery.

IntUrogynecolJ(2010)21:1505–1509ConflictsofinterestNone.

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