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Voiding Dysfunction in TVT Patients

Aug 2012 – by J. Ogburn, MD

Tension free vaginal tape (TVT) is commonly used to treat stress urinary incontinence. The tape is placed in a midurethral position using one of two techniques; a retropubic approach where the tape is placed through the retropubic space and exits in the abdominal wall, or a transobturator approach where the tape is placed through the obturator foramens and exits in the groin. Both approaches are highly effective in relieving stress incontinence with objective success rates approximately 80% for both techniques. (1)

Both techniques are relatively safe and major complications are rare. Complications for both include urinary tract injury, damage to surrounding tissues including bowel, nerves or blood vessels, bleeding, infection, pain and voiding dysfunction. Groin pain is only seen with the transobturator approach while bowel and bladder injury are more likely in the retropubic approach. (2, 3).

Voiding dysfunction is one of the most common complications of TVT - up to 47% of women experience urinary retention or incomplete emptying and up to 25% experience urgency or urge incontinence with the retropubic approach. Rates of voiding dysfunction appear to be lower with the transobturator approach.

Approaches to predict or prevent post-operative voiding dysfunction have had mixed results. Some studies have found a higher rate of retention in patients with a preoperative flow rate of <15 ml/sec while others have shown no difference. Older patients and patients with mixed incontinence have a higher rate of urge postoperatively which may be useful in preoperative counseling. An intraoperative stress test in the awake patient is felt by some to be useful in determining the optimal placement of the tape to treat the incontinence while preventing retention. There is no good data to support performance of an intraoperative stress test. Patients undergoing general anesthesia may have a higher incidence of complications including voiding dysfunction. The procedure should be performed under sedation/local or regional anesthesia if possible.

Management of postoperative retention is initially conservative no matter the surgical approach. A voiding trial should be performed shortly after surgery once the effects of anesthesia have worn off. A post void residual of 100- 150 cc measured by catheterization or ultrasound is abnormal. If the patient is being discharged they can go home with an indwelling catheter or may self-catheterize. If an inpatient then continues voiding trials may be considered. If the retention persists then an indwelling catheter or self-catheterization is appropriate with self-catheterization preferred. A voiding trial should be performed every 3-4 days and the majority of patients will have resolution of symptoms within 10-14 days. Another option in the immediate post-operative period is urethral dilatation. A small caliber Hegar dilator is inserted into the urethra and gentle downward force applied. The goal is to loosen the tape prior to it becoming firmly fixed not to dilate the urethra!

Persistent retention beyond 4-6 weeks occurs in only 1-2 % of patients and typically requires surgical release of the sling. The procedure is relatively simple but requires that the tape be completely transected beneath the urethra. Most patients will have resolution of the retention while maintaining continence.

Urgency or urge incontinence occurs may be persistent from preoperatively or develop de novo. Expectant management, behavioral and/or pharmacologic management is appropriate initially. Most patients will have resolution or significant improvement of the symptoms within 4-6 weeks. Persistent symptoms should be fully evaluated and treated for urge incontinence.

As with any surgery patients undergoing TVT should be counseled preoperatively about common side effects associated with the procedure. Voiding dysfunction is common but fortunately resolves with relatively minor interventions in most patients.

1. Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, Kraus SR, Chai TC, Lemack GE, Dandreo KJ, Varner RE, Menefee S, Ghetti C, Brubaker L, Nygaard I, Khandwala S, Rozanski TA, Johnson H, Schaffer J, Stoddard AM, Holley RL, Nager CW, Moalli P, Mueller E, Arisco AM, Corton M, Tennstedt S, Chang TD, Gormley EA, Litman HJ, Urinary Incontinence Treatment Network. Retropubic versus transobturator midurethral slings for stress incontinence.N Engl J Med. 2010;362(22):2066

2. Brubaker L, Norton PA, Albo ME, Chai TC, Dandreo KJ, Lloyd KL, Lowder JL, Sirls LT, Lemack GE, Arisco AM, Xu Y, Kusek JW, Urinary Incontinence Treatment Network. 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. 2011 Nov;205(5):498.e1-6. Epub 2011 Jul 20

3. Ogah J, Cody JD, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev. 2009