Multi-institute survey on actual conditions of urologic management for severe bladder dysfunction after hysterectomy

We conducted a multi-institute survey on the conditions related to urologic management of severe voiding dysfunction after hysterectomy for uterine cancer with or without postoperative irradiation. Our first study population was a group of adult female patients currently managed by urologists, using clean intermittent catheterization (CIC). Of the 287 patients in this group, 99 (34%) had suffered from uterine cancer. Of these patients, 94 underwent hysterectomy for this disease; 44 and 30 were treated with or without postoperative radiation, respectively, while postoperative irradiation status was unknown for 20. Median follow-up after surgery was 21 (0.2-52) years and median interval from operation to the introduction of CIC was 4.0 (0-49) years. CIC tended to be introduced later for patients with postoperative radiation than those without it. Seventy-four patients, who required invasive urologic interventions other than CIC for voiding dysfunction after hysterectomy, are the second study population. Most of these (82%) had received postoperative irradiation. Continuous Foley catheter placement was the most frequent procedure. Long-term follow-up and urologic management for voiding dysfunction is required for patients undergoing hysterectomy.     

Bladder management after total joint arthroplasty

This study was undertaken to determine the impact of an indwelling Foley catheter on bladder dysfunction and incidence of urinary tract infections after total joint arthroplasty. A prospective randomized controlled trial was conducted assigning use of an indwelling Foley catheter (group 1) or intermittent catheterization (group 2) for 48 hours following operation. Postoperative cultures were obtained on days 2 and 5, and the number of intermittent catheterization events and void and catheterization volumes were recorded. Concurrent cost-effectiveness analysis was conducted. One hundred nineteen of 174 consecutive patients having elective primary total joint arthroplasty completed the study. Five of 62 patients (8%) in group 1 and 7 of 57 patients (12%) in group 2 developed urinary tract infections (NS, P = .45). Twenty patients (35%) in group 2 and 12 (19%) in group 1 required straight catheterization for inability to void 48 hours after surgery (P = .05). Seventeen patients (35%) in group 2 and eight patients (16%) in group 1 required straight catheterization after epidural analgesia was discontinued (P = .024). Bladder management by indwelling Foley catheter saved more than 150 minutes of direct nursing contact per patient and $3,000 in total hospital costs. Indwelling Foley catheters reduced the frequency of postoperative urinary retention, were less labor intensive than intermittent straight catheterization, and were not associated with an increased risk of urinary infection. In the setting of epidural anesthesia and postoperative analgesia for total joint arthroplasty, management by indwelling catheter is a cost-effective strategy to facilitate postoperative return of normal bladder function.     

An alternative statistical approach for predicting prolonged catheterization after burch colposuspension during reconstructive pelvic surgery

Our objective was to use an alternative statistical approach to identify clinical and urodynamic predictors of prolonged catheterization following Burch colposuspension. Seventy women with genuine stress incontinence underwent Burch colposuspension with suprapubic catheter placement at Rush Presbyterian-St. Luke’s Medical Center from 1 July 1992 to 1 October 1993. Patient charts were retrospectively reviewed to extract pertinent variables from their history, examination and preoperative urodynamic evaluation. The day of suprapubic catheter removal was considered the endpoint ‘event’ for the purposes of survival analysis. This statistical model allowed us to identify preoperative clinical parameters important in determining the percentage of patients requiring catheters as a function of time. The need for defining prolonged postoperative catheterization was eliminated. Aging (P=0.01), increasing maximal urethral pressures (P=0.02) and menopausal status (P=0.02) were important in determining the percentage of patients requiring catheters as a function of time. Data from our preoperative voiding studies were not predictive of prolonged catheterization following Burch colposuspension. EDITORIAL COMMENT: Voiding dysfunction remains a significant reality associated with anti-incontinence surgery. Patients should be counseled preoperatively regarding this risk, as voiding dysfunction can dramatically affect quality of life. Many investigators have tried to identify preoperative variables that place the patient at increased risk for postoperative voiding difficulties, with various recommendations given owing to different definitions of abnormal voiding following colposuspension. This paper presents an alternative method to approach prolonged catheterization after incontinence surgery, using survival statistical analysis rather than an arbitrary interval as in previous studies. Using this approach, preoperative voiding study parameters had no association with the length of catheter use. The only significant variable predicting prolonged catheterization was age. These are very different results from previous investigations, which found that decreased detrusor pressure during voiding and maximum flow rates were both associated with prolonged voiding dysfunction. Further investigation is needed in this area, with other centers applying survival statistical analysis to fully clarify whether this approach is valid and, if so, to pinpoint clinically significant variables which would predict postoperative voiding dysfunction.     

Complications associated with the tension-free vaginal tape procedure: the Korean experience

The object was to assess the incidence of complications in patients who had undergone the tension-free vaginal tape procedure and their management. A total of 274 women 28–80 years old (mean: 55.1) with a minimum follow-up of 6 months were included in the study. Follow-up evaluation included questionnaire assessment, physical examination with a stress test, uroflowmetry and postvoid residual urine measurement. Bladder perforations were noted in 13 (4.7%). Thirty-eight patients (13.9%) had postvoid residual urine volume >100 ml twice consecutively or failed to void. Twenty-three women had resolution of their voiding dysfunction with intermittent catheterization. Fourteen patients underwent urethral dilatation and four subsequently underwent a release and/or cutting of the tape. Fifty-seven patients (20.8%) had other voiding problems, but a normal voiding pattern was achieved spontaneously in 34. Fourteen women have shown resolution of their voiding symptoms after urethral dilatation. The present study demonstrates that the tension-free vaginal tape procedure is a safe technique for the treatment of female urinary incontinence. In addition, our findings suggest that there may be a role for urethral dilatation in the management of voiding difficulty associated with the procedure.     

Clinical and urodynamic outcomes of pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence

AIM: We report the clinical and urodynamic outcomes of the pubovaginal sling procedure with autologous rectus fascia for stress urinary incontinence (SUI) and determined the urodynamic parameters that could predict the occurrence of postoperative voiding difficulty. METHODS: Between 1998 and 2005, a total of 29 consecutive women with SUI underwent pubovaginal sling surgery with autologous rectus fascia. Patients were preoperatively and postoperatively evaluated with regard to symptoms and urodynamic findings including uroflowmetry (UFM), postvoid residual urine volume (PVR), filling cystometry (CMG) and pressure flow study (PFS). RESULTS: Overall SUI was cured in 23 patients (80%) and improved in 3 patients (10%). Three patients (10%) who developed persistent urinary retention or severe voiding difficulty after surgery underwent urethrolysis. Of 17 patients who had urgency before the pubovaginal sling, urgency was cured postoperatively in seven, while de novo urgency appeared in one patient. Maximum flow rate (Qmax) in UFM was significantly decreased (P < 0.05) and PVR was increased (P = 0.08) after surgery. PFS showed a significant increase in detrusor opening pressure and detrusor pressure at Qmax (P < 0.01) after surgery. Eight patients (28%) needed prolonged intermittent self-catheterization. Patients who had PVR >100 mL (P < 0.05) or Qmax < or = 20 mL/s (P = 0.09) in preoperative UFM were more likely to require prolonged intermittent catheterization after surgery. CONCLUSIONS: The pubovaginal sling procedure with autologous rectus fascia is an effective treatment for SUI. A comparison of preoperative and postoperative urodynamic parameters indicates an increase in urethral resistance after pubovaginal sling surgery. PVR >100 mL and Qmax < or = 20 mL/s before surgery are risk factors for postoperative voiding difficulty.     

Comparison of 1 and 3 days' transurethral Foley catheterization after retropubic incontinence surgery

This prospective study was done to see if reducing transurethral Foley catheterization from 3 days to 1 would lead to fewer urinary tract infections without an increase in voiding problems. Ninety-one women undergoing retropubic surgery for stress urinary incontinence (Burch or Marshall-Marchetti-Krantz) were randomized to either 1 or 3 days' catheterization. Antibiotics were not used. Infection was diagnosed in 9 (20.0%) patients in the 1-day group and in 16 (34.8%) in the 3-day group. Delayed voiding occurred in 13 (28.9%) and 10 (21.7%) patients, respectively, and 5 (11.1%) and 3 (6.5%), respectively, received a new catheter. The differences do not reach statistical significance. Therefore, catheter time may safely be reduced to 1 day. This may lead to fewer infections but also somewhat more voiding problems. If a transurethral catheter is to be used, on balance the two regimens are equivalent.Editorial Comment: The investigators present a simple and clearly defined study on postoperative voiding management, specifically comparing 1 and 3 day's transurethral Foley catheterization after retropubic surgery. The study is limited by insufficient numbers and the possibility of a type II error in comparing such a small difference in length of Foley use (1 versus 3 days), in terms of the incidence of urinary tract infection or voiding dysfunction. In spite of this limitation, the large number of surgeons utilizing transurethral Foley catheterization following retropubic procedures should find this study of interest, as should those who practise in a managed care environment. Removal of the Foley catheter on postoperative day 1 appears to be a viable alternative, as long as adequate bladder emptying is confirmed.     

Which patients are at risk of voiding difficulty immediately after colposuspension?

The objective of the study was to determine preoperative factors (symptoms, history, clinical findings, urodynamic factors or operative findings) associated with voiding difficulties following colposuspension. This retrospective review was undertaken at a urogynaecological clinic in a large district general hospital. Fifty-one patients who had undergone colposuspension for genuine stress incontinence were included. Voiding difficulty was the main outcome measure. This was assessed by time of spontaneous voiding and time of catheter removal. Age was associated with postoperative voiding difficulty when this was assessed by time of catheter removal (P<0.02) and by time of spontaneous voiding (P<0.05). A low preoperative maximum voiding pressure was associated with delayed spontaneous voiding (P<0.05) but not with prolonged catheterization. It was concluded that older patients were at greater risk of voiding difficulty following colposuspension and that HRT did not prevent this complication.EDITORIAL COMMENT: Factors which definitively predict those patients who will be subjected to prolonged catheterization after incontinence surgery are currently unknown. Age is known to be a factor, as is confirmed by this study, and previously low voiding pressure was also determined to be such a factor [11] and also has been confirmed here. A big factor which has not been addressed in the literature is the effect of the degree of elevation of the vesical neck by the surgical procedure, and its effects on voiding difficulty. It would seem reasonable to assume that a patient with a higher vesical neck and a Q-tip test approximating –30° from the horizontal would void less freely and later than one with a Q-tip test of +10° from the horizontal. It has, however, been this editor's clinical experience that there is no relationship of this anatomy factor to ultimate time of catheter removal. Studies would provide a great deal of information if the degree of elevation of the vesical neck was controlled and accounted for in the analysis of data.     

Concomitant pelvic organ prolapse surgery with TVT procedure

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior–posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12–42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.     

Treatment of urinary complications after total joint replacement in elderly females

Urinary retention and the possible consequence of infection after total joint replacement is an important subject to urologists and orthopedic surgeons. A prospective, randomized study was performed in 77 elderly female patients with total joint replacement to test whether twenty-four-hour catheterization perioperatively or straight catheterization postoperatively in the recovery room might reduce the control group's incidence of postoperative urinary tract infection (9%), urinary retention (57%), and subsequent urinary catheterizations. In 16 percent of the patients who had straight catheterization in the recovery room a urinary tract infection developed postoperatively, and 65 percent of these patients required at least one more catheterization with 13 percent requiring a subsequent indwelling Foley catheter. The patients who had perioperative (immediately preoperatively and for 24 hours postoperatively) catheter drainage had a zero incidence of retention and only a 4 percent incidence of urinary tract infection. We recommend this regimen for elderly female patients undergoing total joint replacement under spinal anesthesia.     

Postoperative urinary tract infections (UTIs) following single-dose intraoperative antibiotic prophylaxis in colposuspension patients

The records of 196 women who underwent colposuspension for genuine stress incontinence at the Leicester General Hospital, England, between June 1991 and May 1996 were reviewed for evidence of urinary tract infection (UTI). Variables analyzed include age, type of anbibiotic, timing of a positive culture, organism(s) responsible and antibiotic sensitivity. Forty-six patients (23.47%) developed urinary infection; of these, 42 had received single-dose antibiotic prophylaxis with suprapubic catheterization. Thirty-two (76%) of those who developed UTI received augmentin (amoxycillin and clavulanic acid), whereas 10 (24%) were given cefuroxime and metronidazole. Positive cultures were obtained between postoperative days 3 and 28, with a mean of 9.6 days, and 81% occurred after the 7th day. Coliform organisms were responsible for nearly 70% of the infections. UTI is still common after colposuspension, despite single-dose antibiotic prophylaxis. Further studies looking at longer or alternative courses of antibiotics or clean intermittent self-catheterization are essential to establish the best way of curbing UTI in urogynecology patients.Editorial Comment: The authors present a summary of their experience with symptomatic urinary tract infection (UTI) after colposuspension, the patients having received a single dose of antibiotics preoperatively. Symptomatic urinary tract infections are described with regard to time of onset, length of suprapubic catheterization, pathogen and antibiotic sensitivity. One of the most interesting findings in this cohort of patients is the incidence of UTI over time, with the majority of infections occurring in the second postoperative week, and falling off dramatically thereafter. This is in contrast to the incidence of urinary tract infections with transurethral catheterization, where published experience suggests at 5%–10% increase in positive cultures for every day of transurethral catheterization, and almost universal positive cultures by 30 days. The results question the utility of preoperative single-dose antibiotic therapy in the prevention of UTI following colposuspension. Further investigation is needed to clarify what prophylactic antibiotic regimen is useful in preventing post-colposuspension infection of the lower urinary tract.     

Long-term results of Burch colposuspension

BACKGROUND: We aimed to determine the long-term results of Burch colposuspension. METHODS: Patients who had undergone Burch colposuspension due to stress urinary incontinence (SUI) in our department between 1991 and 1995 were asked to participate in the study by telephone or mail. Fifty of 78 patients (64%) responded and these formed the study group. Patients were evaluated by a detailed questionnaire, pelvic examination, uroflowmetry and postvoid residual urine determination. Provocative stress test and urodynamic evaluations were performed in those who claimed leakage. Additionally, follow-up charts were retrospectively reviewed from the patients' files. RESULTS: Mean follow-up time was 50.6 months. The subjective cure rate was 52% and the surgical success rate was 84%. The patient satisfaction rate in terms of incontinence was 86%. No correlation was found between pre-operative patient characteristics (i.e. age, number of vaginal deliveries and pregnancies, menopause, previous anti-incontinence surgery and presence of detrusor instability) and outcome of surgery. Although no patient was performing clean intermittent catheterization in the long term, two patients had significant residual urine and obstructive flows. Three patients had severe pelvic prolapse that required surgical correction. CONCLUSIONS: Our results indicate that Burch colposuspension operation is an effective and durable choice of treatment with low complication rates for the treatment of SUI.     

Influences on renal function in chronic spinal cord injured patients

PURPOSE: The optimal method of bladder management in the spinal cord injured population remains controversial. We determined the significance of bladder management and other factors on renal function in this population. MATERIALS AND METHODS: We retrospectively reviewed the medical records and upper tract imaging studies of 308 patients with a mean followup of 18.7 years since injury. Renal function was assessed by serum creatinine, creatinine clearance and proteinuria measurement, and by upper tract abnormalities on renal ultrasound and nuclear medicine renal scan. Independent variables evaluated for an influence on renal function included patient age, interval since injury, injury level and completeness, vesicoureteral reflux, history of diabetes mellitus and bladder management method. RESULTS: Mean serum creatinine plus or minus standard deviation in patients on chronic Foley catheterization, clean intermittent catheterization and spontaneous voiding was 1.08 +/- 0.99, 0.84 +/- 0.23 and 0.97 +/- 0.45 mg./dl. (analysis of variance p = 0.05, Student's t test p = 0.10), and mean creatinine clearance was 91.1 +/- 46.5, 113.4 +/- 39.8 and 115 +/- 49 ml. per minute, respectively (analysis of variance and Student's t test p <0.01), respectively. Proteinuria was present in 19 patients (6.2%) in the Foley catheterization, 3 (1%) in the clean intermittent catheterization and 4 (1.3%) in the spontaneous voiding group (chi-square test p <0.01), while there were upper tract abnormalities in 56 (18.2%), 20 (6.5%) and 24 (7.8%) patients, respectively (chi-square test p <0.01). Multiple regression analyses revealed no significant predictors of serum creatinine, although older patient age and Foley catheterization significantly predicted low creatinine clearance. Additional logistic regression analyses showed that Foley catheterization was associated with proteinuria and vesicoureteral reflux was associated with upper tract abnormalities. CONCLUSIONS: While renal function may be preserved by all forms of bladder management, chronic indwelling catheters may contribute to renal deterioration.     

Urinary tract infections and bacteriuria after gynecological surgery: Experience with 24-hour foley catheterization

The risks of urinary tract infection (UTI) and asymptomatic bacteriuria (AB) associated with short-term catheterization have not yet been established. A prospective observational study was carried out to determine the rates of UTI and AB when transurethral Foley catheterization was used for 24 hours. The study population was 193 women undergoing routine gynecologic surgery. All had negative preoperative urine cultures, and prohylactic antibiotics were not used.Postoperative UTI developed in 16 patients (8.3%), i.e. in only 14 of 86 with a positive culture on day 1 after surgery, and in 2 of 107 with a negative culture on day 1. These 16 women received antibiotics; 79 (40.9%) who had transient AB were not treated. There were no cases of upper UTI. Among 31 women discharged with AB, none developed UTI.Although 49.2% of patients in this study had postoperative bacteriuria as measured by midstream culture, only 8.3% of patients actually developed a symptomatic infection requiring treatment. As only a minority (11.3%) of patients with postoperative AB actually developed UTI, it appears that to treat all cases of bacteriuria >100 000 cfu/ml is unnecessary.     

Voiding dysfunction following cystourethropexy: its evaluation and management

We report on 15 women who underwent cystourethropexy for anatomical stress incontinence and who subsequently had dysfunctional voiding symptoms. All 15 women underwent retropubic takedown of the prior repair and substitution with an obturator shelf repair. All 13 women who had symptoms of bladder instability experienced resolution of these symptoms. Of 7 patients who were in urinary retention and required clean intermittent catheterization only 1 continued to require clean intermittent catheterization to facilitate bladder emptying after obturator shelf substitution. In this series a successful outcome was achieved in 14 of 15 patients (93%).     

A SIMPLE OBJECTIVE METHOD OF ADJUSTING SLING TENSION

PURPOSE: Pubovaginal sling is gaining widespread acceptance as a primary form of treatment for types II and III stress urinary incontinence. However, a major drawback is postoperative obstructed voiding due to excessive force placed on the suspension suture. We describe a simple objective method for intraoperative adjustment of sling tension that can be performed by a single surgeon during pubovaginal sling surgery. MATERIALS AND METHODS: A cotton swab is inserted into the urethra and placed at the urethrovesical junction after the sling is fixed suburethrally and the vaginal mucosa is closed. The suspension sutures are tied down directly onto the rectus fascia with enough tension to keep the cotton swab angle between 0 and 10 degrees to the horizontal plane. A total of 29 patients with an average age of 62 years underwent pubovaginal sling surgery with rectus and cadaveric fascia using this technique for tension adjustment. Of the patients 21 were diagnosed with types II and III, 5 had type II only and 3 had type III only incontinence. Preoperative evaluation revealed detrusor instability in 5 patients. Mean postoperative indwelling catheterization period was 6.2 days. Average followup was 15.6 months. RESULTS: To date no permanent urinary retention has occurred. Of the patients 15 voided without difficulty after catheter removal, 13 had urinary difficulty requiring intermittent catheterization for 1 week or less and 1 had retention requiring intermittent catheterization for 10 weeks. Preoperative symptoms of detrusor instability resolved in all cases. De novo detrusor instability in 3 cases was controlled with anticholinergics. CONCLUSIONS: Overzealous sling tension adjustment has been recognized as a cause of treatment failure leading to urethral obstruction. Our technique is effective in preventing over adjustment of tension, is reproducible and can be performed by 1 surgeon.     

Urethral hypermobility after anti-incontinence surgery—a prognostic indicator?

The aim of this study was to define the concept of hypermobility of the bladder neck and determine its effects on the cure rate and postoperative complications in patients undergoing colposuspension. In a retrospective study, 310 patients who underwent primary colposuspension for urodynamically proven genuine stress urinary incontinence were assessed by introital ultrasound before surgery and during follow-up for up to 48 months postoperatively. A total of 152 women completed 48 months of follow-up. Mobility of the bladder neck during straining was described as linear dorsocaudal movement (LDM) with LDM >15 mm being defined as hypermobility. The overall objective cure rate was 90.0% at 6-month follow-up vs 76.8% at 48-month follow-up (Kaplan–Meier estimators). Urge symptoms occurred in 12.6% (39/310) of the women and de novo urge incontinence in 2.3% (7/310). Bladder neck hypermobility was significantly reduced after anti-incontinence surgery, from 67.1% (208/310) before surgery to 5.5% (17/310) immediately after surgery (P<0.0001). Postoperative hypermobility was associated with a higher recurrence rate. In the hypermobility group, 52.9 and 34.0% of the patients were continent for up to 6 and 48 months, respectively, as opposed to 92.2 and 79.2% in the group without hypermobility (P<0.0001). Women with postoperative hypermobility had a 3.2-fold higher risk of recurrence within 48 months. Bladder neck hypermobility after surgery was also associated with postoperative voiding difficulty (P=0.0278). Patients in whom hypermobility of the bladder neck diagnosed before surgery persists after colposuspension have a higher risk of recurrence and are more likely to develop postoperative complications than those without this hypermobility.     

The effect of early bladder catheterization on the incidence of urinary complications after total joint replacement

A prospective, randomized study was performed in 54 female total arthroplasty patients to determine whether straight catheterization in the recovery room might reduce the incidence of postoperative urinary infection, urinary retention, and urinary catheterization. Thirty-one patients were straight catheterized in the recovery room; 23 were not. Overall, 13% of the patients developed a urinary tract infection postoperatively, 60% of the patients required at least one catheterization, and 13% of the patients required a Foley catheter. No beneficial effect of straight catheterization in the recovery room after arthroplasty was demonstrated.     

Results of modified burch colposuspension in patients with genuine stress incontinence and hypotonic urethra or recurrent stress incontinence

Forty-eight stress-incontinent patients were evaluated before and after a modified Burch colposuspension. Group 1 (n=37) had a hypotonic urethra, and other patients with previous incontinence surgery (n=6) or with reasons for primary laparotomy without pelvic floor relaxation (n=5) formed group 2 (n=11). If pelvic reconstruction was necessary, the Burch procedure was combined with vaginal repair (n=25). After surgery 12 patients (32%) in group 1 complained of subjective recurrent incontinence; four (10%) of them were dissatisfied and 8 (22%) were satisfied with their improvement. Urodynamic examination indicated recurrent stress incontinence in 4 patients. Other reasons for subjective dissatisfaction were detrusor instability, large postvoid bladder volume, voiding difficulties such as straining to void or poor urinary stream, and cystitis. Eight patients with low urethral closure pressure (<=20 cmH₂O) were included in group 1. Only two failed to become continent after Burch colposuspension. Only 1 (9%) patient in group 2 suffered from detrusor instability. Resting urethral closure pressure increased significantly after Burch colposuspension in patients with preoperative hypotonic urethra, including those with low closure pressure. The rate of rectoceles and enteroceles doubled after the Burch procedure if reconstruction of the pelvic floor was not performed. In this study patients who were at high risk for recurrent stress incontinence benefited from the modified Burch colposuspension, but its increased side effects limit its use and require strict indications.Dedicated to Prof Dr med Heinrich Maass on the occasion of his 65^th birthday.     

Incidence and risk factors of postoperative urinary tract infection after uterosacral ligament suspension

Introduction and hypothesis

We assessed the incidence of and risk factors for developing urinary tract infection (UTI) after uterosacral ligament suspension (USLS).

Methods

Retrospective analysis of patients undergoing USLS in 2008–2009 was performed. Postoperative UTI was defined as a positive urine culture within 1 month following surgery. Factors analyzed were patient age, body mass index, parity, history of UTI before surgery, passing voiding trial, discharge with Foley catheter or intermittent self-catheterization, antibiotics at discharge, history of diabetes or renal disease, and surgeon.

Results

Surgical records from 169 patients were reviewed. Twenty-three patients (14%) developed UTI. There were no differences in preoperative factors between patients who developed UTI and those who did not. Subgroup analysis revealed those patients who went home with a Foley catheter and did not receive antibiotics had the highest proportion of UTI.

Conclusion

Patients requiring Foley catheter at discharge following vaginal prolapse repair are at highest risk for UTI and require prophylactic antibiotics.     

Factors predictive of urinary retention after a tension-free vaginal tape procedure for female stress urinary incontinence

PURPOSE: We performed this study to evaluate factors related to urinary retention after a tension-free vaginal tape (TVT) procedure for female stress urinary incontinence. MATERIALS AND METHODS: We retrospectively analyzed the records of 375 women with a followup of at least 6 months from among patients who underwent the TVT procedure between March 1999 and May 2002 at our institution. We analyzed multiple parameters, including patient characteristics, symptoms and urodynamic studies, using univariate and multivariate regression analyses with respect to postoperative urinary retention, as defined by the need for intermittent catheterization for at least 3 days after the procedure. All patients in the nonretention (343) and retention (32) groups answered a global satisfaction question. RESULTS: In answer to a global satisfaction question 338 of the 375 patients (90.1%) favored the procedure. Univariate analysis demonstrated that patient mean age, parity, peak urinary flow and a history of hysterectomy predicted urinary retention. However, on multivariate analyses the peak urinary flow rate was the only significant independent predictive factor (p = 0.007). While 28 patients (87.5%) in the retention group regained normal voiding without a specific procedure, 4 required tape release or cutting within 3 month of surgery. The global satisfaction question showed a significant difference between the nonretention and retention groups (91.5% vs 75% satisfaction, p = 0.03). CONCLUSIONS: An accurate measurement of the peak urinary flow rate could predict women at risk for postoperative urinary retention that compromises global satisfaction after the highly curative TVT procedure.