Introduction

Stress urinary incontinence (SUI) is the most common urinary incontinence in women, affecting about 46 % of adult women, with a peak of 50 % in women over 40 years [ ]. Postoperative urinary retention (POUR) was defined as the inability to void in the presence of a full bladder [ ]. POUR is characterized by an increase in the amount of retained urine after any kinds of surgery and it is a common postoperative complication after gynecological procedures, especially in urinary incontinence and pelvic organs prolapse surgeries [ ]. Although there is no standard definition for POUR, it is characterized by impaired bladder emptying, with an elevation in the volume of retained urine. POUR can be characterized as immediate or delayed, partial or complete, symptomatic or asymptomatic, acute or chronic, obstructive or nonobstructive, and transient or prolonged [ ]. Both pubovaginal slings and Burch colposuspension are less commonly performed today due to higher long-term retention rates (4–10 % and 4–22 %, respectively) [ ]. In contemporary practice, mid-urethral sling (MUS) insertion is considered to be the most effective and safe surgery for SUI [ , ].

The urinary retention rate after surgery for incontinence and prolapse ranges from 2.5 % to 24 %, and even 43 % after transvaginal mesh placement [ , ]. The key of POUR management is to early identification and intervention [ ]. If the clinician did not managed properly, it can cause severe clinical complications, including dysfunction of detrusor muscle, prolonged bladder overdistention, urinary tract infections (UTI), and even surgical repairs’ damages [ ]. Thus, awareness and identification of patients at risk of developing is of great significance [ ].

Few studies on POUR with adequate sample sizes exist in the literature. In this study, we retrospectively assessed the incidence of POUR and identified risk factors for the development of urinary retention after mid-urethral sling placement with and without pelvic reconstructive surgery.

Materials and methods

This retrospective study was conducted at the Division of Urogynecology and Reconstructive Pelvic Surgery, Changhua Christian Hospital, which is a tertiary referral center located in Changhua City, Taiwan. The study was approved by the Institutional Review Board (IRB) of Changhua Christian Hospital for Human Subjects Research (CCH IRB No. 171117).

Consecutive patients with clinically and urodynamically proven urodynamic stress incontinence (USI) between June 2016 and September 2020 were included. All included patients were indicated for surgical treatment of USI, with or without a concomitant reconstructive procedure. Patients with neurogenic bladder, detrusor overactivity, preoperative urine retention or loss to follow-up were excluded. All surgical procedures were performed by a senior urogynecologist with extensive experience in midurethral sling surgery to avoid intersurgical variation. Both transobturator sling (TOT for outside-in and TVT-O for inside-out) and single-incision sling (SIS) devices were freely selected by patients. The TOT was reimbursed by the Bureau of National Health Insurance in Taiwan (NHI) in Taiwan however the SIS was not covered by the Bureau of NHI in Taiwan.

All procedures were performed on the patients in the dorsal lithotomy position. Intravenous cefazolin was given before the operation. General anesthesia was done by anesthesiologist. The TOT and TVT-O procedures were carried out according to previously described techniques [ , ]. A SIS was inserted carefully to ensure the tension of the pillow effect. Cystoscopy was performed in every patient after the insertion of the sling to verify the absence of bladder damage. A urinary catheter was inserted before the placement of the sling and removed the day after the operation for patients without a concomitant reconstructive procedure, and two days after surgery for patients with concomitant reconstructive procedures.

Post-void residual urine (PVR) was measured twice before discharge, with a target voided volume greater than 200 ml and PVR less than 100 ml. If not, the urinary catheter was reinserted again for two days and TOV was repeated twice. The patients were discharged if the voided volume was greater than 200 ml and PVR less than 100 ml (transient POUR). Otherwise, the patients were discharged with an indwelling foley catheter and return to clinic (RTC) 3–7 days later for reassessment (prolonged POUR). These steps are standardized into trial of void (TOV) algorithm in our hospital.

Preoperative assessment included a detailed history taking and physical examination, cough stress test (ST), 1-h pad test (PT), and urodynamic studies, including uroflowmetry, cystometry, PVR, maximal urethral closure pressure (MUCP), and urethral pressure profiles (UPP) measurement. All urodynamic tracings were interpreted by an experienced urogynecologist. USI Type III or intrinsic sphincter deficiency (ISD) is strictly defined as a MUCP <20 cmH2O according to the International Continence Society (ICS). However, we defined MUCP <30 cmH2O as lower MUCP instead of using ISD as parameter for optimizing patient recruitment. Urogenital Distress Inventory six-item questionnaire (UDI-6) and Incontinence Impact seven-item short-form Questionnaire (IIQ-7) were completed before the surgery [ ].

Postoperative follow-up visits were scheduled for one week, and 3, 6, and 12 months after the surgery. All relevant peri-and postoperative complications were documented. Urodynamic testing, PVR, 1-h PT, cough ST and the two validated quality-of-life questionaires were tested again 3 months after surgery. Patients were defined as “objectively cured” when they fulfilled a negative cough ST. While patients were defined as “subjectively cured” when they responded negatively to the third question (Q3) on the UDI-6, “Do you experience urine leakage related to physical activity, coughing, or sneezing?” In addition, we defined age ≧65 years old as advanced age through the general consensus in Taiwan.

We performed statistical analyzes for trends using the Jonckheere-Terpstra test for nonparametric continuous variables and the chi-square test or Fisher’s exact test for categorical variables to find factors associated with the severity of POUR. The Wilcoxon signed-rank test or the McNemar test was used to examine within-group improvement before and after surgery. Finally, multiple logistic regression analysis was used to determine the regression coefficient, odds ratio (OR), and corresponding P value for each putative predictor variable contributing to POUR, after adjusting for possible confounding factors which included adjustments for age, prior hysterectomy, enterocele, lower MUCP, slings, and immediate post-op complications. All data were analyzed using SPSS for Windows statistical package (Version 22.0, Armonk, NY: IBM Corp.). P < 0.05 was considered statistically significant.

Results

Eight hundred and sixty-six patients were included in this study. The demographic characteristics of the participants were shown in Table 1 . There were 673 (77.7 %) patients who received concomitant surgeries of stress urinary incontinence and POP. The most common preoperative severity of POP-Q stage was stage 3 (55.6 %), followed by stage 2 (24.1 %) and stage 4 (20.3 %). There were 193 (22.3 %) patients with anti-incontinence sling alone, 673 (77.7 %) patients with concomitant reconstruction surgery, 413 (47.7 %) patients with concomitant hysterectomy, including vaginal hysterectomy (43.2 %), laparoscopic assisted vaginal hysterectomy (2.2 %), and abdominal total hysterectomy (14.9 %), 129 (14.9 %) patients with uterine suspension, 615 (71.0 %) patients with anterior – posterior vaginal repairs, 596 (68.8 %) patients with enterocele repair, 30 (3.5 %) patients with posterior vaginal repairs, 3 (0.3 %) patients with anterior vaginal repair, and 20 (2.3 %) patients with transvaginal mesh insertion, respectively. Total 686 patients had no POUR (79.2 %), 158 patients had transient POUR (18.3 %), and 22 patients had prolonged POUR (2.5 %). All patients with prolonged POUR were no longer required a Foley catheter within 2 weeks of discharge. Advanced age, prior hysterectomy, prior pelvic reconstruction surgery, and concomitant hysterectomy were associated with higher POUR rates (p < 0.05). Only prior hysterectomy and prior pelvic reconstruction surgery were different between no POUR and persistent POUR groups. Parity, body mass index (BMI), prior incontinence, MUCP, and concomitant reconstruction surgery were not associated with POUR.

All patients were asked to return to the clinic (RTC) 3 months after operation. Cough stress test (ST),1-h pad test (PT), and urodynamic studies, including uroflowmetry, cystometry, PVR, maximal urethral closure pressure (MUCP), and urethral pressure profiles (UPP) measurement were suggested again for postoperative follow-up. Some patients refused to some or all of the tests due to personal reasons, feeling uncomfortable during the tests and/or feeling satisfied with results of the surgery, which caused missing data in our study. However, our RTC rates for cough stress test and uroflowmetry studies were both 81 % while other parameters, including cystometry, MUCP, and UPP measurement were all 77 %.

Pre- and post-operative comparisons of urodynamic parameters are shown in Table 2 , including maximal flow rate (MAX), average flow rate (AVG), PVR, MUCP, and number of MUCP <30 cmH2O. High pre-operation PVR volume was associated with higher rates of transient and prolonged POUR, respectively (p trend<0.05). The post operation PVR of severe POUR patients was lower than that in no POUR and transient POUR patients (p = 0.018); however, the post-surgery MAX, AVG, and MUCP were not significantly different between three groups.

Table 2

Comparison of the pre-operation and post-operation urodynamic parameters changes.

		No POUR					Transient POUR					Prolonged POUR
		N	Median	Q 1	Q 3	P-value a	N	Median	Q 1	Q 3	P-value a	N	Median	Q 1	Q 3	P-value a	P-value b
MAX (ml/sec)	Pre-op	558	18	13	24		131	17	12	23		13	19	12	23		0.253
	Post-op	558	16	12	22	<0.001∗	131	18	13	22	0.455	13	13	11	15	0.054	0.413
	Change	558	−1	−7	4		131	1	−5	5		13	−5	−12	0		0.067
AVG (ml/sec)	Pre-op	558	8	6	11		131	7	5	11		13	9	6	11		0.157
	Post-op	558	7	6	10	<0.001∗	131	8	5	10	0.900	13	6	5	7	0.074	0.595
	Change	558	0	−3	2		131	0	−3	3		13	−2	−4	−1		0.377
PVR (ml)	Pre-op	562	30	12	68		132	31	17	78		14	37	19	85		0.041∗
	Post-op	562	29	10	60	0.049∗	132	33	18	77	0.928	14	16	10	81	0.397	0.018∗
	Change	562	−2	−28	19		132	−2	−28	34		14	−17	−72	22		0.671
MUCP (cmH 2 O)	Pre-op	536	52	37	68		120	53	39	68		12	64	41	80		0.324
	Post-op	536	42	31	55	<0.001∗	120	45	34	57	<0.001∗	12	37	33	51	0.062	0.277
	Change	536	−7	−22	5		120	−6	−19	5		12	−16	−43	1		0.998
MUCP <30, N %	Pre-op	63	11.8				14	11.7				1	8.3				0.829
	Post-op	114	21.3			<0.001∗	21	17.5			0.248	2	16.7			>0.999	0.338

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