NEUROUROLOGY & FEMALE UROLOGY

The evolution of obstruction induced overactive bladder symptoms following urethrolysis for female bladder outlet obstruction
Starkman JS, Duffy JW 3rd, Wolter CE, Kaufman MR, Scarpero HM, Dmochowski RR
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
J Urol. 2008; 179: 1018-23

• Purpose: Bladder outlet obstruction following stress incontinence surgery may present as a spectrum of lower urinary tract symptoms. We evaluated the prevalence and impact of persistent overactive bladder symptoms following urethrolysis for iatrogenic bladder outlet obstruction.
• Materials and Methods: In a retrospective review we identified 40 patients who underwent urethrolysis. All patients underwent a standardized urological evaluation. Patients identified with genitourinary erosion, neurogenic bladder dysfunction and preexisting overactive bladder were excluded. Urethrolysis outcomes were determined by subjective bladder symptoms and objective parameters. Validated questionnaires were completed to assess symptom bother, patient satisfaction and quality of life. Statistical analyses were performed using Stata, version 9.0.
• Results: A total of 40 patients were included in the study with a mean ± SD followup of 13 ± 11 months (range 3 to 38). Of the patients 34 patients presented with obstructive symptoms, while 36 had overactive bladder symptoms. Obstructive symptoms resolved in 28 of the 34 patients (82%), while overactive bladder symptoms resolved completely in only 12 (35%) and they were significantly improved in 4 (12%). Overall 20 patients (56%) were on antimuscarinics for refractory overactive bladder and 8 ultimately required sacral neuromodulation. Pre-urethrolysis detrusor overactivity was more likely in patients with persistent overactive bladder symptoms than in those in whom overactive bladder symptoms resolved (70% vs. 38%). Patients with persistent overactive bladder had significantly greater symptom severity/bother, and decreased perception of improvement and quality of life following urethrolysis.
• Conclusions: Following urethrolysis overactive bladder symptoms may remain refractory in 50% or greater of patients, which has a negative impact on quality of life and the impression of improvement after surgery. Detrusor overactivity demonstrated preoperatively may be useful for predicting who may have persistent overactive bladder symptoms despite an effective urethrolysis procedure.
  
  
• Editorial Comment
  This report highlights the difficulties of achieving normal voiding function after urethrolysis for iatrogenic female bladder outlet obstruction. The authors were able to review 40 patients who underwent a variety of urethrolysis techniques and categorized their operative success on whether the symptoms were primarily obstructive or overactive bladder in nature. The authors noted that it was much easier to resolve obstructive voiding symptoms than those of overactive bladder. The surgical success rate for symptoms of bladder overactivity was under 50 percent; in addition, 20 percent of their overall patients (8/40) eventually needed metachronous sacral nerve stimulation.
  A very well written article that clearly highlights the difficulties in the management of this patient population. Simply addressing the obstructing operation unfortunately will not return the patient to normal voiding function. It is notable that none of the patients in the group appear to have had an obstructing transobturator sling (timing of the original surgery?). The authors highlight that identification preoperatively of detrusor overactivity may be a negative predictor of patient perceived success after their urethrolysis.

Steven P. Petrou, M.D
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu