Saturday, April 19, 2008

Post operative Retention & Urodynamics

One of the less common complications after sling surgery is "post-op retention", essentially, not being able to urinate right away, or rarely, for a awhile.

Hence the use of urodynamics pre-operatively. Urodynamics is like a "stress-test" for the bladder. Instead of getting on a treadmill and running to check your heart, during urodynamics, the patient sits on a commode and the voiding cycle is tested. It usually takes about 20 minutes.

A pediatric catheter is placed into the bladder and another one the same size is placed in the rectum (yes!, but not very far). Also, some patch electrodes are placed on the groin. The bladder catheter serves to fill the bladder and detect bladder pressure during urination, and the rectal catheter assists with the calculation. The patch electrodes help discern if during urination there is adequate sphincter opening or not.

During the test, the patient is asked to cough or strain to provoke a leak to test the "leak pressure".

During bladder filling, the capactiy and compliance of the bladder are gauged.

All in all, its an excellent road map for the urologist trying to determine pre-op parameters in order to help predict outcomes after surgery, or even if surgery should not be done in the first place.

I find it to very useful, and reliable since we have seasoned techs (female) who perform the tests daily.

Getting back to post-op retention. . . As long as the patient has an adequate bladder contraction and voids reflexively (the "normal way") without straining to get the urine out, then post-op retention is unlikely. Factors that can contribute to it include:

Poor bladder functionality/contraction
Strain pattern void
Anesthesia
Post op pain
Other simultaneous procedures performed: cystocele repair, vault prolapse repair, hysterectomy
Overtightening the sling
Age > 70 (in my practice)- this doesn't mean these women can't void- but they may need a urinary catheter for a few days to a week or perform self-cath for about he same time until the bladder "wakes up"

Long-term urinary retention after a sling is very uncommon these days. Current mid-urethral slings are placed "tension free"- (hence the acronym TVT= tension free tape) have very low long term retention rates. It also greatly depends on who's doing the sling surgery- to make it "just right"- not too tight or not too loose. Since modern day slings are not stitched or anchored to fascia or bone, retention is uncommon.

Older slings, such as "bone-anchored slings" or pubo-fascial slings" are fixed to structures and require some degree of guesswork/finesse/luck/experience to place it just right.

In terms of TVT-type slings of the modern age, if the sling is SLIGHTLY to snug, women will notice a weakened stream, intermittent stream, incomplete emptying or urgency/frequency. New onset urgency after sling is less than 10%, and the majority do resolve within 3 months. Even a weak stream does improve after 2-12 weeks as the bladder accomodates to the sling.

What if it still too tight?
If after 3 months there are still problems, this can be confirmed by repeat urodynamics, and if the bladder is "obstructed", then the sling should be cut.

Does this compromise the effect of the sling and lead to recurrent incontinence? It can happen in 20-50% of women. The sling should be cut at the 6 o'clock position and allow lateral release of the sling. There should still enough scar laterally on both sides to keep the urethra supported.

It pays to go someone who does MANY.

Coming next. . . .Cystocele (Bladder Drop)

Sunday, April 6, 2008

How Long is Recovery after a Sling?

Sling procedures for Stress Urinary Incontinence usualy take about 20-30 minutes and are performed as an outpatient.

I councel patients to "take it easy" for 72 hours after the procedure. Most women can go back to work thereafter (as long as work is not very physically demanding usually)

I advise patients to not do any heavy exercise for 2-3 weeks (biking, aerobics, spinning, hiking) but walking is acceptable.

No sex, baths or pools for 6 weeks!

If any other vaginal prolaspe problem exists, these can be repaired at the same time. And most are outpatient as well.

A web review of an article I've published

Here is a web review of an article I've published on mesh use in pelvic floor repair by a comprehensive urology website:

http://www.urotoday.com/index.php?option=com_content&task=view&id=2340&Itemid=48

It has also been sited as a reference in other publications also reviewing pelvic floor repair and mesh.

http://www.indianjurol.com/article.asp?issn=0970-1591;year=2007;volume=23;issue=2;spage=153;epage=160;aulast=Nazemi

http://www.co-urology.com/pt/re/courology/abstract.00042307-200607000-00007.htm;jsessionid=H4MLZBbnYzXvLqsXh711Sc1vTT3gGbnbfxkpbhJG00GWLGYGlRmd!132671813!181195628!8091!-1