Suprameatal transvaginal urethrolysis

We describe and assess a method of urethrolysis using a transvaginal suprameatal approach without lateral perforation of the urethropelvic ligament.

Between March 1993 and December 1997, 32 consecutive women 32 to 79 years old underwent suprameatal transvaginal urethrolysis at 2 institutions. In all cases anti-incontinence surgery was done previously, including a pubovaginal sling procedure in 12, Marshall-Marchetti-Krantz procedure in 8, Burch colposuspension in 6, modified Pereyra transvaginal urethropexy in 4, and Gittes suspension and anterior repair in 1 each. Of the 32 patients 20 were in urinary retention and 12 had primarily urge and/or irritative voiding symptoms, or urge incontinence. In the patients in urinary retention average maximal detrusor pressure was 41.4 cm. water. In all cases physical examination, cystourethroscopy and video urodynamics were done before suprameatal transvaginal urethrolysis. Obstruction was defined as detrusor pressure greater than 20 cm. water at maximum urinary flow of less than 12 ml. per second. Urethral obstruction was presumed when examination revealed urethral angulation, tethering, narrowing or scarification. Impaired detrusor contractility was diagnosed when detrusor pressure at maximum urinary flow was less than 20 cm. water at maximum urinary flow of less than 12 ml. per second.

After suprameatal transvaginal urethrolysis 13 of the 20 women (65%) in urinary retention voided well and in 8 of the 12 (67%) with urgency symptoms resolved. Postoperative stress urinary incontinence developed in only 1 case.

The success rate of suprameatal transvaginal urethrolysis to treat urinary obstruction associated with anti-incontinence procedures compares favorably to that of other described alternative approaches. The success rate in patients with definite urodynamic criteria for obstruction was not significantly better than in those who underwent suprameatal transvaginal urethrolysis based on physical examination and clinical judgment. Preoperative maximal urinary flow rate was associated with operative success (p = 0.018), while preoperative post-void residual urine and maximum detrusor pressure failed to reveal a difference between operative success and failure.