Predictors of early postoperative voiding dysfunction and other complications following a midurethral sling.
BACKGROUND
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.


OBJECTIVE
The objective of the study was to identify preoperative predictors for failed voiding trial following an isolated midurethral sling.


METHODS
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 χ2tests as appropriate. Multivariable stepwise logistic regression was used to determine predictors of failing a voiding trial.


RESULTS
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.


CONCLUSIONS
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.
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX. Electronic address: Christopher.Ripperda@utsouthwestern.edu.
Christopher M
CM
Ripperda
Department of Obstetrics and Gynecology, University of Iowa, Iowa City, IA.
Joseph T
JT
Kowalski
Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA.
Zaid Q
ZQ
Chaudhry
Department of Obstetrics and Gynecology, Stanford University, Palo Alto, CA.
Aman S
AS
Mahal
Department of Gynecology and Obstetrics, Emory University, Atlanta, GA.
Jennifer
J
Lanzer
Department of Obstetrics and Gynecology, Mount Auburn Hospital/Harvard Medical School, Cambridge, MA.
Nabila
N
Noor
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
Meadow M
MM
Good
Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, TX; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX.
Linda S
LS
Hynan
Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM.
Peter C
PC
Jeppson
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
David D
DD
Rahn
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology*; D057234:Preoperative Period; D012189:Retrospective Studies; D053825:Suburethral Slings; D016896:Treatment Outcome; D014550:Urinary Incontinence, Stress / Q000601:surgery; D014555:Urination Disorders / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D055815:Young Adult
early postoperative complications; midurethral sling; voiding dysfunction