Surgeries for SUI are not without hazards. Proper preoperative assessment, patient counseling, meticulous postoperative care& early discovery of complications are the mainstays of management. Voiding difficulty after anti-incontinence surgeries can become persistent and have a significant impact on quality of life. Supra-pubic catheter & CISC should be added to our practice. Careful surgical technique with avoidance of over-elevation might play a role in prevention of VD.

1. Postoperative care & management
after SUI operations
Wafaa B. Basta
Consultant Gynaecology & Obstetrics at Mataria Teaching Hospital,
MRCOG
ERC MEMBER

3. Complications of MUS
• Intra-operative
– Major
• Vascular lesions < 0.01%
• Nerve injuries < 0.0005%
• Gut lesions < 0.007%
– Minor
• Bladder injury 0.5–14%
• Repeated bladder injury
1.2%
• Peri-operative
– Retropubic haematoma 2–
4.3%
– Blood loss > 200 ml 2.7–3.3%
– Urinary tract infections 10%
– Spondylitis 0.3–0.8%
• Post-operative
– Transient urinary retention
1.4–15%
– Permanent urinary retention
2.4–2.8%
– Vaginal erosion 0.7–33%
– Urethral erosion 2.7–33%
– De novo urgency 7.2–25%
– Bladder erosion 0.5–0.6%
– Urethral obstruction 3.6–
6.4%
Managing Complications after Midurethral Sling for Stress Urinary Incontinence
Elisabetta Costantini *, Massimo Lazzeri, Massimo Porenae a u - e b u update s e r i e s 5 ( 2 0 0 7 ) 232–240

4. Pre-operative Counseling
• Voiding difficulty is common .
• Go home with a catheter maybe required .
• Detrusor over-activity might be unmasked.
• More time should be spent counselling at risk
group.
• Preoperative CISC training.

5. Prediction of voiding difficulty
• risk factors for postoperative voiding
dysfunction:
– Advanced patient age (decrease detrusor
contractility, increase urethral rigidity ).
– Patients who undergone prior prolapse surgery,
prior incontinence surgery.
Cho ST, Song HC, Song HJ, et al. Predictors of postoperative voiding dysfunction Following transobsturator sling procedures in
patients with stress urinary incontinence. Int Neurourol J. 2010;14:26.

6. Prediction of voiding difficulty
• pre-operative urodynamics:
– the presence of a high post-void residual volume.
– the use of Valsalva effort to void = Abdominal
straining (abdominal pressure rise during voiding).
– Low maximum detrusor pressure. ( >15-20 cm
H2O).
– Peak flow rate--- less than 15 ml /second .
Kraus SR, Lemack GE, Richter HE, et al. Changes in urodynamic measures two years after Burch colposuspension or autologous sling
surgery. Urology. 2001;78:1263.
Mutone N, Brizendine E, Hale D. Factors that influence voiding function after the tension-free vaginal tape procedure for stress
urinary incontinence. Am J Obstet Gynecol. 2003;188:1477.

7. The management of voiding difficulty after incontinence surgery
Luigi Bombieri, Robert M Freeman TOG 2003;5:66-71

8. Pre-operative Measures
• Treatment of UTI.
• Diabetes control.
• Correction of anaemia.
• Explore persistent risk factors : cough,
increased IAP,…..

9. Proper surgery selection
• Short-term voiding difficulties following Burch
procedure appear to be more likely than
following TVT
Ward K, Hilton P. United Kingdom and Ireland Tension-free Vaginal Tape Trial Group, et al: Prospective multicentre
randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ
2002; 325:67.

10. Proper surgery selection
• TOT have been found to promote a lower rate
of postoperative voiding dysfunction than
retropubic TVT.
• Urinary retention and de-novo urgency / urge
incontinence is less likely when using the
transobturator versus the retropubic approach
.
Schierlitz L, Dwyer PL, Rosamilia A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women
with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol.
2008;112:1253.

11. Proper surgery selection
• Retrospective data suggests that resolution of
pre-operative detrusor overactivity is greater
in patients undergoing TOT as compared to
retropubic midurethral slings and bladder
neck slings (47 % resolution versus 35 % and
14 % respectively)
Gamble TL, Botros SM, Beaumont JL, et al. Predictors of persistent detrusor overactivity after transvaginal sling
procedures. Am J Obstet Gynecol. 2008;199:696 e1.

12. Prediction of ISD
• Abdominal leak point pressure = ALPP >
60cmH2O.
• Maximal uretheral closure pressure= MUCP
>20 cm H2O.
• + loss of uretheral motility
• Low tension retropubic tape / rectus sling are
preferred than Burch /TVT

13. Intra-operative measures
• Proper surgical technique.
• Use the procedure you are confident with &
the tape you are familiar with.
• Cystoscope when required.
• Conscious effort to avoid over-elevation of the
bladder neck .
• Consider suprapubic catheter if VD is
anticipated.

14. Patient post-operative instructions
• Drink plenty of water (8 glasses/day) but without
overdoing.
• Voiding at regular intervals (3-4 hours during the
day).
• Avoid constipation.(laxatives).
• Good analgesia.
• No intercourse ,no weight bearing for 6 weeks.
• local estrogen in post-menopause is
controversial.

15. Patient post-operative instructions
• Relax rather than pushing as pushing will cause
the urine flow to stop .
• Give the bladder plenty of time to empty.
• Provocation by tape water sound or putting
hands in cold water.
• Try standing or leaning forward during voiding
• Double voiding.
• Urine stream may feel slow and weak initially but
will become stronger with healing.

16. Post-operative voiding assessment
& managing Voiding Dysfunction

20. Supra-pubic catheter
• Is preferred than uretheral in the short term VD:
– more practical
– allow patients to attempt urethral voiding without the
need to be re-catheterised .
– The residual urine volume can be measured directly
– Lower incidence of significant bacteriuria compared to
urethral catheters
– voiding occurs earlier.
– patient acceptability appears to be higher.
– Less sexually inhibiting in cases of long term use.
– Less bypass & blockage.
– No urethral stricture or erosion.
Andersen JT,H eiscecberg L, Hebjorn !$ Peersen K, S m p e Sorensen S. Fischer-Rumurren W. et a/.
Suprapubic versus cnnsuttthnl bladder drainage &er colposuspension/vaginal repair.
Ada Obsfrf Gynccol Sand 1985;6(:139-43.

21. Supra-pubic catheter
• Initial insertion requires
training, surgical skills and
equipment.
• Risk of bowel perforation,
(in adhesions and
contracted bladder)
• Better to be inserted intra-
operative.
• Under local anaesthesia?
patient acceptance?
• Availability ?

22. Supra-pubic catheter
• Granulation at
cystostomy entry site.
• Bypassing of urine via
cystostomy channel.
• Skin ulcers.
• Limited time to insert a
new catheter if the
catheter is pulled or fell
out.

25. CISC (advantages)
• Freedom from urinary
collection systems .
• Allow catheterization at
times convenient to individual
lifestyles.
• CISC can reduce and avoid the
risk of :
• infection
• blockage
• Encrustation
• catheter rejection
• pain
• trauma.

26. CISC
• Is based on the principle that retention rather than
catheterisation is the cause of infection.
• Used as a short-term or a long-term strategy.
• The frequency of catheterisation depends on the
severity of the voiding disorder and residual urine
volume.
• Voiding should be attempted before every
catheterisation, and PVR measured and recorded, if
possible.
• Patient motivation is essential, the majority of VD
resolve within 12 weeks after CISC.

27. The role of drug therapy in managing VD
• Alpha-adrenoreceptor antagonists to relax the urethra (e.g.
phenoxybenzamine hydrochloride)
• Detrusor-stimulating drugs such as cholinergic agents (e.g.
bethanechol chloride), anticholinesterase (e.g. distigmine
bromide)
• Prostaglandins.
• An uncontrolled non randomised study found diazepam to be
more effective than other drugs.
• Due to their inconsistent effect and unproven value, drugs are
not currently recommended for the prevention and treatment
of postoperative voiding difficulty.
Stanton SL. cudou, LD, Kcrr-Whn R.Trcatment of delayed o mof spontaneous voiding afar s u m
for incontinence. U m l 1~97 9;13:494-6.

28. The role of surgery in VD
• Urethral dilatation and urethrotomy
– Effective in urethral narrowing
– recurrence of scarring- worsening obstruction
– stress incontinence reappear.
• Supra-pubic and vaginal ‘take-down’ procedures involving urethrolysis,
with or without additional re-suspension procedures:
– suitable for patients who are unwilling or unable to perform CISCI
– cases of voiding difficulty combined with urge symptoms.
– reported success rate is variable and unpredictable
– risk of recurrent stress incontinence

29. The role of surgery in VD
• After TVT procedures:
– Loosening of the tape by applying gentle
downward traction.
– or alternatively transection of the tape (if scarring
does not allow the tape to descend), ------
immediate symptomatic relief.
– The risk of recurrence of SUI has been reported to
be low after both methods.

30. Vaginal mesh erosion
• Can be managed:
– conservative
– non conservative
• Depends on:
– erosion site
– Extension
– mesh material
– patient’s clinical status.
• Oestrogen:
– favour spontaneous
healing in small erosion
– prepare the vagina for
surgical repair.

31. Vaginal mesh erosion
• If synthetic materials e.g
polyester and silicone slings,----
mesh removal ( epithelialisation
is unlikely ).
• if autologous, allograft and new,
loosely woven polypropylene
material -----conservative
management with observation (
tissue ingrowth and healing).
• the self-fixing nature of
polypropylene may allow the
integration into surrounding
tissues .

32. Vaginal mesh erosion
• Kobashi et al suggested that when the
vaginal epithelium appears to cover
the mesh but has not completely
grown over all of it, further
observation might be considered
• Up to approximately 1 cm of mesh
exposure should become
epithelialised within 6 wk.
• Larger areas ----- longer observation
period.
• When the erosion involves the vagina
and is 1 cm, one should preserve the
sling.
• If no starting or partial overgrowth is
evident by 3 mo postoperatively, sling
removal should be seriously
considered.

33. Vaginal mesh erosion
• Surgical approach :
– partial, simple excision
of the exposed mesh
– surgical exploration for
total graft removal and
tissue reconstruction

34. Bladder erosion
• Primary : (perforation)
– perioperative
complication
– evident at cystoscopy
– prevalent after TVT.
– drainage for 2–4 d.

35. Bladder/uretheral erosion
• Secondary: (erosion)
– not evident at cystoscopy
– emerges weeks later
– due to submucosally placed tape .
– Polypropylene mesh contact with
urine--- tape incrustation, no
possibility of correcting the tape
position .
– The earlier a misplaced tape is
explanted, the fewer the scars, the
less inflammation, and the easier
complete removal.
– In selected, complicated cases,(
stones, bleeding, or recurrent
infection) , an open suprapubic
approach with cystotomy is
recommended

36. De novo urgency
• negative impact on QOL
• sometimes self-limiting.
• rule out :
– urethral erosion
– intra-vesical tape
– urinary retention
– Recurrent UTI.
• If persist
– oral anti-muscarinic agents are first-line.
• If fails:
– intra-vesical vanilloids
– intra-detrusor injection of botulinum toxin
– sacral neuro-modulation.

37. Retzius haematoma
• Surgical evacuation of Retzius haematoma is
rare.
• Bleeding usually originates from pelvic floor
veins or epigastric vessels.
• Evacuation is decided on the basis of the
patient’s clinical condition.

38. Conclusion
• Surgeries for SUI are not without hazards.
• Proper preoperative assessment, patient counseling,
meticulous postoperative care& early discovery of
complications are the mainstays of management.
• Voiding difficulty after anti-incontinence surgeries can
become persistent and have a significant impact on
quality of life.
• Supra-pubic catheter & CISC should be added to our
practice.
• Careful surgical technique with avoidance of over-
elevation might play a role in prevention of VD.

39. Thank You