Voiding dysfunction after anti-incontinence surgery

Voiding dysfunction after incontinence surgery is a potential complication of all stress incontinence procedures. The term voiding dysfunction indicates from obstructive voiding symptoms up to complete urinary retention, requiring intermittent catheterization, and also includes irritative storage symptoms such as de novo urgency and detrusor overactivity. Of particular importance is the temporal relationship between symptoms and the previous surgical procedure, and although many different operations can result in voiding dysfunction, the most common cause remains attributable to hypersuspension of the urethra. The diagnosis of postoperative voiding dysfunction can be challenging. First of all surgeons must ask for an accurate history, in order to assess symptomatology and to carry out a physical examination. Further diagnosis could be done through urodynamics, but this is somewhat controversial: despite various proposed cut-off values, there are no absolute urodynamic criteria to define obstruction in women. Fortunately, most voiding dysfunction is transient and resolves spontaneously in a few days to weeks. Persistent voiding dysfunction (longer than 4 weeks) occurs in 5-20% after the Marshall-Marchetti-Krantz procedure, 4-22% after the Burch colposuspension, 5-7% after needle suspension, 4-10% after the pubovaginal sling procedure, and 2-4% after the trans-vaginal tape procedure. However, if symptoms persist, surgery is indicated. Several surgical approaches are described, including sling incision, sling lysis and formal urethrolysis, comprising vaginal and retropubic approach with or without graft interposition. In this article the procedures are described and the results of each type of urethrolysis are reported.