Urethral Obstruction

1. Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of UrologySUNY Downstate Medical Center

2. Urethral Obstruction • Incidence: 2 - 29% of women with persistent LUTS • Symptoms: nothing characteristic • storage 29% • voiding 8% • both 63% BBlaivas & Groutz, , Neurourol & Urodynam 19:553, 2000; Nitti et al, J Urol, 1999

3. Diagnosis • Suspect in: • all women with low Q • with grade 3 & 4 POP • sx onset after incontinence/ prolapse surgery • Urodynamics (synchronous pdet / Q) • Cystoscopy

4. Urethral obstruction • High detrusor pressure(pdet > 20 cm H20) • Low uroflow(Qmax < 12 ml/S)

5. 2 Low flow High pressure Strss

6. Impaired Detrusor Contractility • Weak & or poorly sustained detrusorcontraction (pdet < 20 cm H20) • Low flow (Qmax < 12 ml/S)

7. Low flow Low pressure JK

8. Blaivas - Groutz Nomogram

9. Diagnosis • ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” • No specific UDS criteria • Obstructed women had: • lower Qmax • higher Pdet@Qmax • higher PVR • 23% of 331 women were obstructed Nitti et al, J Urol, 1999

10. Caveats • A pressure flow diagnosis is usually definitive, but • An acontractile detrusor or impaired detrusor contractility does not rule out obstruction • Persistent voiding dysfunction after incontinence surgery is usually due to obstruction

11. Etiology Groutz et al, Neurourol Urodyn 19:213,2000; Nitti et al., 1999

12. Urethral Obstruction in women • Anatomic • Functional

13. Anatomic Urethral Obstruction • Compression • Post surgical • Prolapse • Urethral Diverticulum • Tumor • Urethral stricture • Post surgical • Traumatic • Idiopathic • Atrophy

14. Functional Urethral Obstruction • Primary vesical neck • Neurogenic • Acquired behavior

15. Rx Anatomic Urethral Obstruction • Intermittent catheterization • Surgery - depends on the cause: • correct prolapse • sling incision / urethrolysis • urethral diverticulectomy • urethroplasty

16. Rx Functional Urethral Obstruction • Primary vesical neck • TUI / TUR of vesical neck • ? Alpha adrenergic antagonists • Neurogenic • Intermittent catheterization +/- • anticholinergics • Botox • enterocystoplasty • Dysfunctional voiding • Bmod / biofeedback / neuromodulation

17. Anatomic Urethral Obstruction • Compression • Post surgical • Prolapse • Urethral Diverticulum • Tumor • Urethral stricture • Post surgical • Traumatic • Idiopathic • Atrophy

18. Low flow MSCO High pressure

21. Rx of Post-op Obstruction • First 3 months – monitoring vs intervention • May experience improvement • Depends on procedure done • After 3 months • Improvement unlikely • Definitive treatment

22. Mid Urethral Sling Loosening(1-2 weeks) • Local anesthesia • Open vaginal suture line • Hook sling with a right-angle clamp • Spread clamp or downward traction on the tape will usually loosen it (1-2 cm) • If the tape is fixed, it can be cut

23. Sling Incision • Pull down on Foley and palpate sling • Inverted U or midline incision • Begin urethral dissection just proximal to sling • Isolation of sling in the midline or lateral • Incision of the sling Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR, Urology 59:47, 2002

24. DS

25. Sling Incision • Sling should spring apart • If not, dissect it from urethra • +/- urethrolysis

29. TVT Intervention Results NTypeSuccess Klutke, et al* 17 Midline Incision 100% normal emptying Rardin, et al** 23 Midline Incision 100% normal emptying Loosening 30% complete resol. irritative sx 70% partial resol. irritative sx * Recurrent SUI in 6% ** Significant recurrent SUI 13%26% recurrent SUI, but significantly better than prior to TVT

30. Sling Incision Results NTypeSuccess SUI Klutke, et al Urology 58:697, 2001 Nitti, et al 19 Midline Incision 84% 17% Amundsen, et al 32 Various 94% retention 9% 67% UUI Goldman 14 Midline Incision 93% 21%

31. Transvaginal Anterior vaginal wall Suprameatal Retropubic Urethrolysis

32. Inverted U incision Lateral dissection superficial to PCV Endopelvic fascia perforated & retropubic space entered Transvaginal Urethrolysis

33. Sharp and blunt dissection urethra freed from lateral attachments & undersurface of the pubic bone Index finger placed between pubic bone and urethra +/- Martius flap interposition Transvaginal Urethrolysis

41. Urethrolysis Results NTypeSuccess SUI Foster & McGuire 48 Transvaginal 65% 0 Nitti & Raz 42 Transvaginal 71% 0 Cross, et al 39 Transvaginal 72% 3% Goldman, et al 32 Transvaginal 84% 19% Petrou, et al 32 Suprameatal 67% 3% Webster & Kreder 15 Retropubic 93% 13% Petrou & Young 12 Retropubic 83% 18% Carr & Webster 54 Mixed 78% 14%

42. Retropubic Urethrolysis • Mobilization of urethra by sharp dissection • Restore complete mobility to anterior vaginal wall • Paravaginal repair • Interposition of omentum between urethra and pubic bone

43. Anatomic Urethral Obstruction • Compression • Post surgical • Prolapse • Urethral Diverticulum • Tumor • Urethral stricture • Post surgical • Traumatic • Atrophy

44. Qmax = 8 ml/S Pdet @ Qmax = 36cm H2O

45. symphysis urethra

46. Qmax = 2 ml/S, Pdet @ Qmax = 54 cm H2O

47. symphysis Prolapsedbladder

48. Anatomic Urethral Obstruction • Compression • Post surgical • Prolapse • Urethral Diverticulum • Tumor • Urethral stricture • Post surgical • Traumatic • Atrophy

49. FS Qmax = 5 ml/S Tic pdet@Qmax = 68 cm H20

50. Anatomic Urethral Obstruction • Compression • Post surgical • Prolapse • Urethral Diverticulum • Tumor • Urethral stricture • Post surgical • Traumatic • Atrophy