Transvaginal urethrolysis for urethral obstruction

Abstract

Urethral or bladder outlet obstruction (BOO) following anti-incontinence procedures is an infrequent but significant complication affecting women with stress urinary incontinence, with an incidence ranging between 2% and 8% in the literature. Symptoms of bladder outlet obstruction following these procedures may present as urinary retention, incomplete emptying, or weakened stream in the more immediate postoperative period; however, a significant number of women with BOO experience more subtle symptoms of de novo urgency and irritative symptoms, and thus may have delayed presentation and diagnosis. There are several proposed definitions and criteria for diagnosing BOO based on urodynamics; however, ultimately there are no standardized definitions, and patients with true BOO may be missed with these definitions. The treatment for female BOO with mid-urethral synthetic or autologous slings is often sling incision or excision. For more complex repairs, suspension procedures, or failed sling incisions, a more formalized urethrolysis is typically required. With advanced technologies, surgeons have now incorporated both laparoscopic and robotic techniques in performing urethrolysis, in addition to the traditional transvaginal approaches. The timing of urethrolysis from initial anti-incontinence procedure has been examined in several studies, and although the issue remains debated, there is an increasing trend to perform sling incision or urethrolysis earlier due to concerns for persistent lower urinary tract symptoms despite correction of the bladder outlet obstruction. The most common complication from sling incision or urethrolysis is recurrent stress urinary incontinence; this must be balanced with concerns over delayed intervention. Further study is necessary for delineating long-term validated patient-reported outcomes and examining comparative effectiveness of the various repair techniques.