Why do women have voiding dysfunction and de novo detrusor instability after colposuspension?

Abstract

Objective To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension.Design Prospective, observational study.Setting Urogynaecology unit, district general hospital.Population Seventy-seven women undergoing colposuspension for genuine stress incontinence. MethodsThe following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors. Main outcome measures 1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively. Results Pre-operative peak flow rate ( P ¼ 0.004), straining during voiding ( P ¼ 0.005), increasing age ( P < 0.001), operative elevation ( P < 0.001) and anterior urethral compression ( P ¼ 0.001) were associated with the number of days of post-operative catheterisation. Increasing age ( P ¼ 0.02), previous bladder neck surgery ( P ¼ 0.04), operative elevation ( P ¼ 0.049) and anterior urethral compression ( P < 0.001) were associated with detrusor instability at three months. Conclusion Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.

Determination of bladder neck position by intraoperative introital ultrasound in colposuspension: outcome at 6‐month follow‐up

“…Stanton and other groups showed that the modified technique had similar cure rates of 50–80% after 5–20 years4, 5, 9, 10, 12. Nevertheless, 5–50% of the patients develop postoperative urgency symptoms, de novo urge incontinence or residual urine with voiding difficulties6–11, 13. A major problem to be solved is the lack of objective criteria or a standard for determining the optimal level of elevation.…”

“…Colposuspension2 continues to be the method of choice and has not been replaced as the gold standard of incontinence surgery by recently introduced operative methods such as tension‐free vaginal tape3. Despite fairly good results after 10 years with a cure rate of 69%4, 5, approximately 20% (range, 5–50%) of women develop bladder voiding disturbance and de novo urge incontinence due to excessive correction6–11. Although some controversy exists12, many investigators agree that excessive correction may lead to voiding dysfunction, urge incontinence, enterocele and rectocele6, 11, 13–16.…”

“…Despite fairly good results after 10 years with a cure rate of 69%4, 5, approximately 20% (range, 5–50%) of women develop bladder voiding disturbance and de novo urge incontinence due to excessive correction6–11. Although some controversy exists12, many investigators agree that excessive correction may lead to voiding dysfunction, urge incontinence, enterocele and rectocele6, 11, 13–16. Despite this association between these adverse events and the degree of bladder neck elevation, the latter is determined subjectively by the surgeon at his or her discretion and it is far from clear what represents the optimal level of elevation.…”

“…Despite this association between these adverse events and the degree of bladder neck elevation, the latter is determined subjectively by the surgeon at his or her discretion and it is far from clear what represents the optimal level of elevation. Some authors have proposed more objective methods for determining the optimal level of elevation6, 15, 17–20, but none of these is truly convincing.…”

Die Kolposuspension zur Behandlung der weiblichen Stressinkontinenz

“…Unabhängig von der sinnvollen präoperativen lokalen Estrogenisierung zur Verbesserung von Proliferationsgrad, Kollagengehalt und Verbesserung der lokalen Flora sollte bei Frauen im höheren Alter nur eine sparsame Elevation des Blasenhalses angestrebt, jede Überkorrektur vermieden werden [21,22]. postoperative Miktionsstörungen; mit jeder Lebensdekade steigt allerdings das Risiko der funktionellen Obstruktion steil an.…”