FEMALE UROLOGY

Delayed treatment of bladder outlet obstruction after sling surgery: association with irreversible bladder dysfunction
Leng WW, Davies BJ, Tarin T, Sweeney DD, Chancellor MB
Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
J Urol. 2004; 172(Part 1 of 2): 1379-81

• Purpose: Our urethrolysis cohort demonstrated an unusual delay time to surgical treatment of bladder outlet obstruction. We determined whether urethrolysis outcomes, i.e. persistent bladder symptoms, were associated with time between sling and urethrolysis surgeries.
• Materials and Methods: Retrospective analysis of all patients who underwent urethrolysis for post-sling voiding dysfunction between June 1997 and June 2002 was performed. We excluded from study 6 patients with a known history of overactive bladder symptoms, neurogenic bladder dysfunction and use of anticholinergic pharmacotherapy before stress incontinence surgery. The remaining 15 patients were stratified into 2 outcomes groups based upon the absence or presence of post-urethrolysis bladder storage symptoms. Patients (7) in group 1 have no current bladder symptoms. Patients (8) in group 2 still require anticholinergic drug therapy for significant bladder symptoms of frequency and urgency. Data collected for the 2 groups included mean age, existence of urinary retention before urethrolysis, mean time to urethrolysis in months, urethrolysis outcome based upon subjective bladder symptoms and followup duration. For comparison of mean age between groups, the standard t test was used. Fisher’s exact test was used to compare frequency of urinary retention before urethrolysis between groups. Lastly, the Mann-Whitney U test was conducted to compare time to urethrolysis between groups. All statistical analyses were conducted using the SPSS software package (SPSS, Inc., Chicago, Illinois).
• Results: There was no statistically significant difference between the groups with respect to age or frequency of urinary retention before urethrolysis. Time to urethrolysis for the whole cohort ranged from 2 to 66 months. Mean followup after urethrolysis was 17.3 +/- 22.9 months. Comparison of mean time between incontinence and urethrolysis surgeries between group 1 (9.0 +/- 10.1 months) and group 2 (31.25 +/- 21.9 months) demonstrated a statistically significant difference (p = 0.01).
• Conclusions: This urethrolysis population demonstrated an unusual delay time to surgical treatment of bladder outlet obstruction. We categorized the cohort according to absence or presence of persistent bladder storage symptoms, and found a strong association between persistent bladder symptoms and greater delay to urethrolysis.
  
  
• Editorial Comment
  The authors review their specific population of urethrolysis patients and retrospectively analyze the response to surgery and its relation to the passage of time between the original sling and the subsequent urethrolysis. The analysis revealed a strong association between persistent bladder symptoms and greater delay to urethrolysis.
  This paper is very timely in view that it raises the issue of when should one intercede for relief of obstruction secondary to an outlet procedure. The paper may have a had a greater degree of illumination had there been more definition of the urinary symptoms preoperatively and postoperatively. During the review of the paper, one may infer that the authors assume that all their urethrolysis patients were surgically successful and that the continuation of symptoms was basically due to anatomic/physiologic changes associated with obstruction as opposed to technique failure. Nevertheless, the take home message from this paper is that as soon as the diagnosis of infravesical outlet obstruction is diagnosed it should be definitively remedied; this may be valuable advice indeed when deciding when to intercede with this specific subset of patients.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida, USA