Risk of Failure and Complications

Clinical conditions that increase the risk of surgical failure for retropubic urethropexy include obesity, menopause, prior hysterectomy, and prior anti-incontinence proce-

dures. Advanced age does not seem to be associated with lower rates of cure after colposuspension. Urodynamic findings that increase the risk of surgical failure include signs of intrinsic urethral sphincter deficiency, abnormal perineal electromyography, and concurrent detrusor over-activity. Patients with intrinsic sphincter deficiency probably are better treated with a sling procedure if the urethral is hypermobile, or with periurethral injections of a bulking agent, if the urethra is nonmobile.

Detrusor overactivity or urge incontinence may coexist in up to 30% of patients with stress incontinence. The term mixed incontinence has been used to describe this condition. In addition, approximately 15% of patients with stress incontinence who have a preoperative stable cystometro-gram, develop de novo overactive bladder after a colpo-suspension. The course of the detrusor overactivity after a retropubic repair in patients with mixed incontinence is unpredictable. Interestingly, as many as 50% to 60% of patients with mixed incontinence are cured of their detru-sor overactivity by surgical support of the bladder neck. A much smaller percentage (approximately 5%-15%) have worsening of their overactivity with the remainder (20%-30%) having persistence of their overactivity. Women with high-pressure detrusor overactivity or poor bladder compliance are more likely to have persistent urge incontinence after incontinence surgery. In general,women with mixed incontinence should initially receive nonsurgi-cal therapy, followed by surgery if they have persistent stress incontinence that remains bothersome.

Detrusor overactivity is a recognized postoperative complication of retropubic procedures. Postoperative detrusor overactivity is more common in patients with previous bladder neck surgery and in those with mixed detrusor overactivity and stress incontinence preoperatively. In a study of 148 patients with urodynamic stress incontinence and stable bladders preoperatively, Steel et al.11 reported that 24 patients (16.2%) had postoperative detrusor over-activity on cystometrogram 6 months after surgery. Ten of the 24 patients with detrusor overactivity were completely asymptomatic. Of the 14 symptomatic patients, four were improved with drugs aimed at correcting the overactivity. The remaining 10 patients (6.8%) remained symptomatic with detrusor overactivity 3 to 5 years after surgery.

Wound complications and urinary infections are the most common surgical complications after retropubic col-posuspension. Direct surgical injury to the urinary tract occurs relatively infrequently. Bladder lacerations occur in approximately 1% of patients; the risk increases in women who have had previous bladder neck suspension. Accidental placement of sutures into the bladder during the Burch colposuspension or paravaginal repair, resulting in vesical stone formation, painful voiding, recurrent cystitis, or fistula can occur but is rare. Ureteral obstruction occurs rarely (0%-1.2%) after Burch colposuspension and results from ureteral stretching or kinking after elevation of the vagina and bladder base. No cases of transected ureters have been reported.

The incidence of voiding difficulties after colposuspen-sion varies widely, although patients rarely have urinary retention after 30 days. In my hands, the mean number of days to complete voiding after open Burch procedure is 7 days.12 Colposuspension can change the original micturition pattern and introduce an element of obstruction that can disturb the balance between voiding forces and outflow resistance, resulting in immediate postoperative as well as late voiding difficulties. Urodynamic findings that may occur after colposuspension include decreased flow rate, increased micturition pressure, and increased urethral resistance. In a study conducted at our institution, risk factors for prolonged voiding after a bladder neck suspension included advanced age, previous incontinence surgery, increased first sensation to void, high postvoid residual volume, and postoperative cystitis.12 Abdominal straining during voiding was not associated with prolonged voiding after surgery.

Burch2 first reported that enteroceles occurred in 7.6% of cases after the Burch procedure, but only two-thirds of these patients required surgical correction. Langer et al.13 reported that 13.6% of patients who had undergone Burch procedures,but no hysterectomy or cul-de-sac obliteration, developed an enterocele 1 to 2 years postoperatively.Alcalay et al.8 noted that 26% of patients during a 10- to 20-year follow-up period after Burch colposuspension underwent a rectocele repair and 5% underwent an enterocele repair. Whenever possible, a cul-de-sac obliteration in the form of uterosacral suspension or plication should be considered at the time of retropubic suspension to prevent enterocele formation, although the true efficacy of this prophylactic maneuver is unknown. Rectocele repair should be performed as indicated for symptomatic or large rectoceles.

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