The document discusses voiding dysfunctions after sling surgery for stress urinary incontinence. It notes that voiding dysfunctions occur in 2-20% of patients after various sling procedures. The causes can include excessive tension on the sling, displacement of the sling, or external compression of the urethra. Diagnosis involves evaluating the patient history and symptoms, as well as urodynamics testing and imaging exams. Treatment options include conservative measures like clean intermittent catheterization, or surgical interventions like sling loosening or incision if conservative options fail. Early sling loosening or incision within 2 weeks of surgery appears to effectively resolve voiding dysfunction in many patients without compromising continence.

1. Disfunzioni
uretro-vescicali
dopo sling:
quale approccio?
Marco Torella
Dipartimento della Donna, del Bambino e di
Chirurgia Generale e Specialistica
Centro Interdisciplinare del Pavimento Pelvico
Seconda Università degli Studi di Napoli

2. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
2010
Definition & Symptoms
“Voiding dysfunction, a diagnosis by
symptoms and urodynamic investigations,
is defined as abnormally slow and/or
incomplete micturition”

3. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Definition & Symptoms
 Urinary frequency
 Urgency
 Urge incontinence

4. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Etiology
Robinson et al., Defining Female Voiding Dysfunction: ICI-RS
2011, Neurourol Urodyn, 2012

5. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Epidemiology
Rates of voiding dysfunction after surgery for SUI:
 4 to 22% for Burch colposuspension
 5 to 20% for Marshall-Marchetti-Krantz urethropexy
 4 to 10% for pubovaginal sling
 5 to 7% for needle suspension
 2 to 4% for TVT
Dunn et al., Int Urogynecol J Pelvic Floor Dysfunct 2004
The most important factor in reducing obstruction has
probably been the appreciation that operations for SUI work
by restoring support and not by changing the position of the
urethra!

6. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 Excessive tension on the sling around or under the urethra
 Displacement of the sling
from its intended position
 Kinking/angulation of the urethra or external compression
(e.g. from vaginal prolapse that was not corrected at the
time of incontinence surgery or that occurred after
surgery)
 Failure of relaxation of the striated urethral sphincter
 Impaired detrusor contractility (relative obstruction)
Pathogenesis
Voiding symptoms

7. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Bladder outlet obstuction
Altered receptor function
Myogenic denervation
Imbalance of neurotransmitters Detrusor overactivity
Lluel et al., J Urol 1998
Pathogenesis
Storage symptoms

8. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
1.9 to 19.7% after RP-MUS
vs
1.5 to 5.5% after TO-MUS
RP vs TO slings
J Urol 2008
 Urinary retention:
 De novo urgency:
5.9 to 25% after RP-MUS
vs
2.9 to 15.6% after TO-MUS

9. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 The prevalence of storage LUTS was significantly higher in those
patients randomized to RT (OR: 1.35; 95% CI OR: 1.05–1.72; p =
0.02), without any significant difference between inside-out and
outside-in TOT.
 A nonstatistically significant difference in favor of TOT was found
for voiding LUTS (OR: 1.56; 95% CI OR: 0.97–2.5; p = 0.07).
RP vs TO slings
Eur Urol 2010

10. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 Prospective randomised trial at two Swiss teaching hospitals
 Uroflow rate was primary endpoint
 Eighty TVT, 40 transobturator out-in TOT and 40 in-out TVT-O were
randomised
 At 12 months, there was no difference in Qmax among the groups
RP vs TO slings

11. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Is prediction possible?
 341 women were randomized to receive “inside-out” or “outside-
in” TO-TVT
 There were no differences in preoperative urodynamic parameters
among those with and those without VD.
 Preoperative urodynamic parameters did not predict the
development of short-term voiding dysfunction after a TO-
TVT procedure.

12. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 History
 Symptoms (inability to void, slow/interrupted stream, straining to void and/or
frequency, urgency, urge incontinence)
 Patient’s preoperative voiding status and symptoms
 Temporal relationship of LUTS to the surgery
 Type of procedure performed and number and type of other procedures done
 Preoperative urodynamic data, if available
 Physical Examination
 Overcorrection or hypersuspension → ‘fixed’ urethra
 Cystocele and other forms of prolapse
 Persistent urethral hypermobility and stress incontinence
Diagnosis

13. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Diagnosis
Urodynamics
High pressure, low flow voiding dynamics
 In case of urinary retention,
urodynamics may not be
necessary before intervention,
particularly if preoperative
testing showed normal voiding.
 However, in cases of de novo or
worsened storage symptoms
without a significantly elevated
PVR, an urodynamic evaluation
is preferred.

14. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Urology 2004
After adjusting for age and
using asymptomatic controls
rather than an incontinent
control population, they
presented pressure-flow
study cut-off values for the
diagnosis of female BOO:
 Qmax of ≤ 11 ml/s
 Pdet Qmax of ≥ 25 cm
H2O

15. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Diagnosis
Videourodynamics
 Pressure-flow studies alone may
fail to diagnose obstruction but
simultaneous imaging of the
bladder outlet during voiding
greatly facilitates diagnosis.
 BOO can be diagnosed when a
radiographic evidence of an
obstruction between the bladder
neck and distal urethra is
associated with a sustained
detrusor contraction of any
magnitude during voiding.
Nitti et al., J Urol 1999

16. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Diagnosis
Imaging & Endoscopy
 Perineal ultrasound:
 To determine the position of the sling along the
urethra
 Voiding cystourethrogram:
 To determine narrowing, kinking or deviation of the
bladder, bladder neck and urethra during voiding
 Urethrocystoscopy:
 May show scarring, narrowing occlusion, kinking,
or deviation of the urethra
 Inspection of the urethra and bladder for eroded
sutures or sling material and the presence of a fistula

17. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Management
 Conservative treatment:
 Clean intermittent self-catheterization
 Anticholinergics or pelvic floor
physiotherapy (for patients who are
emptying well but have significant
storage symptoms)
 Urethral dilation (82% cured or improved –
Karram et al., Obstet Gynecol 2003)
 Surgical intervention:
 Early loosening of the tape
 Sling incision
 Urethrolysis

18. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 Twenty-two (5.6%) of 389 women who underwent a TVT
operation developed post-operative voiding dysfunction. Twenty
women commenced self-catheterization (CISC) and their progress
was monitored.
 Voiding function returned to normal with CISC in 72% of patients
and of these, 85% were cured in less than 12 weeks.
 CISC is a suitable and effective initial approach to managing
the majority of cases of voiding dysfunction and avoids the
risks associated with further surgery.

19. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Management
Sling loosening or incision
 Vaginal incision and tape identification
 The sling is hooked with a right-angle clamp (or a Metzenbaum scissors).
 Spreading of the right-angle clamp or
downward traction on the tape will usually
loosen it (1-2 cm). This is usually possible if
intervention is done by 7-14 days.
 Thereafter, tissue ingrowth may
prevent loosening of the sling, in
which case cutting it in the midline
is recommended.
 Incision closure

20. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Management
Urethrolysis
 If sling incision is not successful in relieving obstruction
 May be accomplished through a retropubic or a transvaginal approach
 Transvaginal approach is easier to perform and has reduced morbidity and
recovery time
 Retropubic space is entered sharply by
perforating the attachment of the endopelvic
fascia to the obturator fascia
 The urethra is dissected off the undersurface
of the pubic bone and completely freed
proximally to the bladder neck
 Penrose drain placed around the urethra

21. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
 After TVT incision, resolution of obstruction in all 17 patients while
recurrent SUI occurred in one patient.
 Impaired bladder emptying resolved in 100% of 23 patients after TVT
incision and/or loosening, with 61% remaining continent, 26% with partial
recurrence, and 13% with complete recurrence of SUI.
 Forty-nine percent of the patients were completely cured of their retention
and remained continent after transvaginal tape release.
 Successful resolution of voiding dysfunction in 29 out of 33 women
with no recurrence of incontinence after early loosening of the tape.
Management
Is there a risk of recurrent SUI?
Klutke et al., Urology 2001
Rardin et al., Obstet Gynecol 2002
Laurikainen and Kiilhoma, Int Urogynecol J Pelvic Floor Dysfunct 2006
Price et al., Int Urogynecol J Pelvic Floor Dysfunct 2009

22. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Int Urogynecol J, 2013
Int Urogynecol J, 2015

23. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Take home messages
 There is a lack of consensus in how to manage postoperative voiding
dysfunction.
 Most women regain a normal voiding function in the first few days after surgery,
as postoperative edema and pain resolve.
 It seems reasonable, therefore, to start with conservative measures (e.g. CISC)
and to reserve surgery for those women with resistant symptoms or for those
who are unsuitable for CISC.
 Among surgical options, early transvaginal tape mobilization appears to be a
simple and effective procedure that can be performed within the first 2 weeks
after sling placement without compromising continence.

24. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Int Urogynecol J, 2010

25. Disfunzioni uretro-vescicali dopo sling: quale approccio? – M. Torella
Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica - Seconda Università degli Studi di Napoli
Grazie per l’attenzione!