URETHROLYSIS
What is it?
An operation for the treatment of obstruction or blockage of the urethra, usually resulting from anti-incontinence surgery such as a sling, tape or bladder suspension procedure.
What are the symptoms of urethral obstruction?
Urethral obstruction inhibits the flow of urine out of the bladder. The bladder may respond by becoming overactive, resulting in symptoms of urinary urgency or urge incontinence.
This is a sudden compelling desire to pass urine that is difficult to postpone and may be associated with a fear of leakage or actual leakage. Patients may need to pass urine frequently during the day or night.
Urethral obstruction may also result in poor bladder emptying, a poor urinary stream, straining to pass urine, hesitancy, a feeling of incompletely emptying and needing to double void. The bladder may fail to empty completely. A consequence of this can be bladder infections.
Symptoms usually occur from the outset, (immediately after the anti-incontinence operation), but can have a delayed onset up to years later.
What does a urethrolysis involve?
The procedure is usually done via a vaginal incision. Sometimes an abdominal incision is also required. The urethra is freed up from the surrounding scarred tissues which are trapping it and holding it in an over-elevated position. If a TVT or other synthetic tape has been used, it is divided or a segment of tape is removed. If a fascial sling was used this is usually just divided. Sometimes sutures need to be divided, requiring an abdominal incision. An abdominal approach may also be used if a previous urethrolysis by a vaginal approach has failed. Sometimes tissue from within the labia is used to support and protect the urethra. This is called a ‘Martius labial fat pad graft’.
Usually the urethrolysis does not result in the return of stress incontinence. But, in about 10% stress incontinence returns requiring a subsequent procedure to treat this.
If there is both stress incontinence and obstruction then another incontinence procedure may be performed at the same time as the urethrolysis.
What are the alternatives?
Medication may help control urgency and an overactive bladder, Intermittent self catheterisation can be used to empty the bladder, and antibiotics may control urine infections. As these are usually required on an ongoing basis most patients wish to attempt to have the underlying problem corrected.
Will it work and for how long?
Urethrolysis will cure the obstruction in about 65 – 75% of patients without the return of incontinence. These cure rates may be less, as low as 33% in patients with a weak bladder demonstrated on urodynamic studies.[1] Even following urethrolysis, the flow of urine may still be slower and take a longer time to empty than originally.
How long does the operation take?
About one hour. It does depend on what sort of urethrolysis is being performed and on the previous type of surgery.
What is the usual post-operative course?
A urinary catheter and vaginal pack, placed during surgery are removed the following day.
The nursing staff will chart how often you pass urine and how much you pass. A bladder scan is performed to see if you empty completely.
Some patients may experience difficulty completely emptying their bladder initially. This is managed by learning to pass a small catheter via the urethra to empty the bladder, (Intermittent Self Catheterisation). This will prevent the bladder from becoming overdistended as this may delay the return of voiding to completion even more. Intermittent selfcatheterisation is usually performed until the post-void residuals are < 100ml.
It is not uncommon for this to be required in the early post-operative period due to swelling around the urethra from the surgery.
If a Martius graft is performed there will be a small wound drain in the labia which is removed after 1-2 days.
Patients are usually discharged the next day after surgery.
Other instructions for when you go home.
It takes about 1 week to return to normal activity if only a vaginal incision is required and about 2-4 weeks if an abdominal incision is required and depending on what the original antiincontinence operation was.
It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 2-3 weeks. When this has stopped and the vaginal wound has healed you can have sexual intercourse, or use tampons, as comfortable (usually by 3 weeks).
It is usual to have some wound pain post-operatively but this mainly resolves by 2-4 weeks. Usually this is controlled with paracetamol. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day).
What are the risks and complications?
Urinary retention – inability to pass urine requiring catheterisation. If the operation fails to relieve urethral obstruction, it may need to be repeated, sometimes by a different approach, e.g. abdominal incision. Inability to empty the bladder can also result from a weak bladder, rather than urethral obstruction.
Urinary fistula – damage to the urethra can result in leakage of urine usually from the vagina.
Urethral stricture – scarring can result in obstruction returning at a later date.
Return of stress incontinence – if this occurs another operation may be required to treat it.
Urinary urgency will usually get better after a urethrolysis. If not medication may be required to control it. There is a small risk of patients developing urgency as a new symptom after urethrolysis.
Other problems that may occur following surgery include; urine infection, wound infection, wound breakdown, haematoma (collection of blood), seroma (collection of fluid), bleeding from the wound, in the pelvis or in the urine.
If a Martius labial fat pad is performed, uncommon problems reported following this include pain with intercourse, intermittent discomfort at the wound, numbness, or altered appearance of the labia.[2]
There are also general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses associated with surgery. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
There is a small risk of death; less than 5 in 10,000.
There is a small risk of bleeding requiring a blood transfusion; 3-5%.
Injury to the bladder, urethra or ureter are uncommon. If the bladder or urethra are perforated a catheter will usually need to remain in for 5-10 days.
Bowel, nerve or vascular injuries are rare. Complications may require further surgery.
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
Post-operative follow-up.
You will be given a follow up appointment. If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Bleeding
- Wound problems – infection or breakdown
- Inability to pass urine or a catheter if required
- Or any other significant trouble.
If at any stage in the future your incontinence or obstructive symptoms return you should arrange a review visit.
References
1. Austin, P., et al., Urethral obstruction after anti-incontinence surgery in women: evaluation, methodology, and surgical results. Urology, 1996. 47(6): p. 890-4.
2. Petrou, S.P., J. Jones, and R.O. Parra, Martius flap harvest site: patient selfperception. J Urol, 2002. 167(5): p. 2098-9.
Version: V3, July 2017
