Romero Maroto Jesús, Prieto Chaparro Luis, López López Cristobal, Quilez Fenoll José Manuel, Rodríguez Fernández Elena
Hospital Universitario de San Juan, Universidad Miguel Henández, San Juan, Alicante, España.
Arch Esp Urol. 2002 Nov;55(9):1107-14.
To report our experience in the diagnosis and treatment of the lower urinary tract obstruction after urinary incontinence corrective surgery, analysing the different techniques performed, retropubic or vaginal urethrolysis.
We report a series of 14 patients with the diagnosis of obstruction after incontinence corrective surgery. They were classified in 2 groups, those who underwent retropubic procedures (5 cases) and those who underwent prolene mesh sling procedures (9 cases). We detail preoperative clinical-urodynamic parameters, and postoperative bladder outlet obstruction confirmation. Retropubic urethrolysis was performed in all patients after retropubic surgery, with the association of hysterectomy if indicated. The performance of a new sling- urethropexy was individualized. In three cases of retropubic surgery repeated urethropexy was not done. Unilateral section was performed in the sling series for all except one case of double section. A new mesh sling was performed in two cases; two cases did not undergo reoperation. Urethrolysis results were evaluated both subjectively by satisfaction degree scales and objectively by clinical-urodynamic evaluation, comparing clinical data and urodynamic parameters using the proper statistical test.
In the retropubic surgery group all patients are continent. Satisfaction degree is: very satisfied 3 patients and 2 quite satisfied. Two presented with voiding urgency not needing anticholinergic drugs, and their urodynamic data returned to normal values without post void residual. The obstructed patients in the sling group reported minimal urgency after urethrolysis in 2 cases. Two patients have stress urinary incontinence: one of them is better than before and refused to undergo a new operation; the other one, who repeated sling, developed a clinical picture of urgency-incontinence again, underwent second section and continues having stress urinary incontinence. Among 7 patients undergoing sling, 4 are very satisfied, 1 quite satisfied, 1 somewhat satisfied and 1 not at all satisfied. Voiding difficulties have disappeared in all cases; comparisons between pre and postoperative urodynamics maximum flow, detrusor pressure at maximum flow and postvoid residual show statistically significant differences. Post-urethrolysis parameters return to preoperative values.
The immediate development of symptoms after surgical correction of urinary stress incontinence is the best diagnostic criteria for obstruction. Detrusor muscle responds to obstruction, but sometimes its response is so minimal that it is difficult to diagnose urodynamically. The knowledge of preoperative values helps to confirm the diagnosis. In any case, urodynamic parameters did not influence the success of urethrolysis. Urethrolysis is an effective operation to cure symptoms secondary to obstruction after incontinence corrective surgery. When a sling has been the procedure performed, probably it is not worth to perform a standard urethrolysis; a simple section of one of the branches seems to be enough to improve symptoms. Currently, there is not scientific evidence about the convenience or not of bladder neck-urethral re-suspension after urethrolysis. The only case-scenario in which it is clearly indicated is that when there is stress incontinence in addition to obstructive symptoms.
报告我们在尿失禁矫正手术后下尿路梗阻的诊断和治疗经验,分析所采用的不同技术,即耻骨后或经阴道尿道松解术。
我们报告了一系列14例诊断为失禁矫正手术后梗阻的患者。他们被分为两组,一组接受耻骨后手术(5例),另一组接受聚丙烯网带悬吊手术(9例)。我们详细介绍了术前临床尿动力学参数以及术后膀胱出口梗阻的确认情况。所有耻骨后手术后的患者均进行了耻骨后尿道松解术,如有指征则联合子宫切除术。新型吊带尿道固定术的实施是个体化的。在3例耻骨后手术中未重复进行尿道固定术。在吊带组中,除1例进行双侧切断外,其余均进行了单侧切断。2例患者进行了新型网带悬吊;2例未再次手术。通过满意度量表主观评估尿道松解术的结果,并通过临床尿动力学评估客观评估,使用适当的统计检验比较临床数据和尿动力学参数。
耻骨后手术组所有患者均实现控尿。满意度为:非常满意3例,比较满意2例。2例患者出现排尿急迫感,但无需使用抗胆碱能药物,其尿动力学数据恢复至正常水平,且无残余尿量。吊带组的梗阻患者中,2例在尿道松解术后报告急迫感轻微。2例患者存在压力性尿失禁:其中1例情况较术前改善,拒绝再次手术;另1例重复吊带手术后再次出现急迫性尿失禁的临床表现,接受了二次切断,目前仍存在压力性尿失禁。在接受吊带手术的7例患者中,4例非常满意,1例比较满意,1例有些满意,1例完全不满意。所有病例的排尿困难均已消失;术前和术后尿动力学最大尿流率、最大尿流时逼尿肌压力和残余尿量的比较显示出统计学上的显著差异。尿道松解术后参数恢复至术前值。
压力性尿失禁手术矫正后症状的即刻出现是梗阻的最佳诊断标准。逼尿肌对梗阻有反应,但有时其反应非常轻微,以至于难以通过尿动力学诊断。术前值的了解有助于确诊。无论如何,尿动力学参数并不影响尿道松解术的成功率。尿道松解术是治疗失禁矫正手术后梗阻继发症状的有效手术。如果已经进行了吊带手术,可能不值得进行标准的尿道松解术;简单切断其中一个分支似乎足以改善症状。目前,关于尿道松解术后膀胱颈 - 尿道重新悬吊是否合适尚无科学证据。唯一明确指征的情况是除梗阻症状外还存在压力性尿失禁。