Ripperda Christopher M, Kowalski Joseph T, Chaudhry Zaid Q, Mahal Aman S, Lanzer Jennifer, Noor Nabila, Good Meadow M, Hynan Linda S, Jeppson Peter C, Rahn David D
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
Department of Obstetrics and Gynecology, University of Iowa, Iowa City, IA.
Am J Obstet Gynecol. 2016 Nov;215(5):656.e1-656.e6. doi: 10.1016/j.ajog.2016.06.010. Epub 2016 Jun 16.
The rates reported for postoperative urinary retention following midurethral sling procedures are highly variable. Determining which patients have a higher likelihood of failing a voiding trial will help with preoperative counseling prior to a midurethral sling.
The objective of the study was to identify preoperative predictors for failed voiding trial following an isolated midurethral sling.
A retrospective, multicenter, case-control study was performed by including all isolated midurethral sling procedures performed between Jan. 1, 2010 to June 30, 2015, at 6 academic centers. We collected demographics, medical and surgical histories, voiding symptoms, urodynamic evaluation, and intraoperative data from the medical record. We excluded patients not eligible for attempted voiding trial after surgery (eg, bladder perforation requiring catheterization). Cases failed a postoperative voiding trial and were discharged with an indwelling catheter or taught intermittent self-catheterization; controls passed a voiding trial. We also recorded any adverse events such as urinary tract infection or voiding dysfunction up to 6 weeks after surgery. Bivariate analyses were completed using Mann-Whitney and Pearson χ tests as appropriate. Multivariable stepwise logistic regression was used to determine predictors of failing a voiding trial.
A total of 464 patients had an isolated sling (70.9% retropubic, 28.4% transobturator, 0.6% single incision); 101 (21.8%) failed the initial voiding trial. At follow-up visits, 90.4% passed a second voiding trial, and 38.5% of the remainder passed on the third attempt. For the bivariate analyses, prior prolapse or incontinence surgery was similar in cases vs controls (31% vs 28%, P = .610) as were age, race, body mass index, and operative time. Significantly more of the cases (32%) than controls (22%) had a Charlson comorbidity index score of 1 or greater (P = .039). Overactive bladder symptoms of urgency, frequency, and urgency incontinence were similar in both groups as was detrusor overactivity in those with a urodynamic evaluation (29% vs 22%, P = .136), but nocturia was reported more in the cases (50% vs 38%, P = .046). Mean (SD) bladder capacity was similar in both groups (406 [148] mL vs 388 [122] mL, P = .542) as was maximum flow rate with uroflowmetry and pressure flow studies. Cases were significantly more likely to have a voiding type other than detrusor contraction: 37% vs 25%, P = .027, odds ratio, 1.79 (95% confidence interval, 1.07-3.00). There was no difference in voiding trial failures between retropubic and transobturator routes (23.1% vs 18.9%, P = .329). Within 6 weeks of surgery, the frequency of urinary tract infection in cases was greater than controls (20% vs 6%, P < .001; odds ratio, 3.51 [95% confidence interval, 1.82-6.75]). After passing a repeat voiding trial, cases were more likely to present with acute urinary retention (10% vs 3%, P = .003; odds ratio, 4.00 [95% confidence interval, 1.61-9.92]). For multivariable analyses, increasing Charlson comorbidity index increased the risk of a voiding trial failure; apart from this, we did not identify other demographic information among the patients who did not undergo urodynamic evaluation that reliably forecasted a voiding trial failure.
The majority of women will pass a voiding trial on the first attempt after an isolated midurethral sling. Current medical comorbidities are predictive of a voiding trial failure, whereas other demographic/examination findings are not. Patients failing the initial voiding trial are at an increased risk of postoperative urinary tract infection or developing acute retention after passing a subsequent voiding trial.
报道的经尿道中段吊带术术后尿潴留发生率差异很大。确定哪些患者排尿试验失败的可能性较高，将有助于在经尿道中段吊带术前进行术前咨询。
本研究的目的是确定单纯经尿道中段吊带术后排尿试验失败的术前预测因素。
进行了一项回顾性、多中心、病例对照研究，纳入了2010年1月1日至2015年6月30日期间在6个学术中心进行的所有单纯经尿道中段吊带手术。我们从病历中收集了人口统计学、医疗和手术史、排尿症状、尿动力学评估和术中数据。我们排除了术后不符合尝试排尿试验条件的患者（例如，膀胱穿孔需要留置导尿管）。病例组排尿试验失败，出院时留置导尿管或学会间歇性自我导尿；对照组排尿试验通过。我们还记录了术后6周内的任何不良事件，如尿路感染或排尿功能障碍。根据情况使用Mann-Whitney检验和Pearson χ²检验进行双变量分析。采用多变量逐步逻辑回归确定排尿试验失败的预测因素。
共有464例患者接受了单纯吊带手术（耻骨后70.9%，经闭孔28.4%，单切口0.6%）；101例（21.8%）初次排尿试验失败。在随访中，90.4%的患者第二次排尿试验通过，其余患者中有38.5%在第三次尝试时通过。在双变量分析中，病例组和对照组之前的脱垂或尿失禁手术情况相似（31%对28%，P = 0.610），年龄、种族、体重指数和手术时间也是如此。病例组Charlson合并症指数评分为1或更高的比例（32%）显著高于对照组（22%）（P = 0.039）。两组的膀胱过度活动症状（尿急、尿频和急迫性尿失禁）以及进行尿动力学评估的患者中的逼尿肌过度活动情况相似（29%对22%，P = 0.136），但病例组夜尿症的报告更多（50%对38%，P = 0.046）。两组的平均（标准差）膀胱容量相似（406[148]mL对388[122]mL，P = 0.542），尿流率和压力流研究中的最大尿流率也相似。病例组出现非逼尿肌收缩排尿类型的可能性显著更高：37%对25%，P = 0.027，比值比为1.79（95%置信区间为1.07 - 3.00）。耻骨后和经闭孔途径的排尿试验失败率没有差异（23.1%对18.9%，P = 0.329）。在术后6周内，病例组尿路感染的发生率高于对照组（20%对6%，P < 0.001；比值比为3.51[95%置信区间为1.82 - 6.75]）。在通过重复排尿试验后，病例组更有可能出现急性尿潴留（10%对3%，P = 0.003；比值比为4.00[95%置信区间为1.61 - 9.92]）。在多变量分析中，Charlson合并症指数增加会增加排尿试验失败的风险；除此之外，我们在未进行尿动力学评估的患者中未发现其他可靠预测排尿试验失败的人口统计学信息。
大多数女性在单纯经尿道中段吊带术后首次尝试排尿试验时会通过。目前的医疗合并症可预测排尿试验失败，而其他人口统计学/检查结果则不能。初次排尿试验失败的患者术后发生尿路感染或在通过后续排尿试验后发生急性尿潴留的风险增加。
