Suprameatal transvaginal urethrolysis

Purpose: We describe and assess a method of urethrolysis using a transvagin al suprameatal approach without lateral perforation of the urethropelvic li gament. Materials and Methods: Between March 1993 and December 1997, 32 consecutive women 32 to 79 years old underwent suprameatal transvaginal urethrolysis a t 2 institutions. In all cases anti-incontinence surgery was done previousl y, including a pubovaginal sling procedure in 12, Marshall-Marchetti-Krantz procedure in 8, Burch colposuspension in 6, modified Pereyra transvaginal urethropexy in 4, and Gittes suspension and anterior repair in 1 each. Of t he 32 patients 20 were in urinary retention and 12 had primarily urge and/o r irritative voiding symptoms, or urge incontinence. In the patients in uri nary retention average maximal detrusor pressure was 41.4 cm. water. In all cases physical examination, cystourethroscopy and video urodynamics were d one before suprameatal transvaginal urethrolysis. Obstruction was defined a s detrusor pressure greater than 20 cm. mater at maximum urinary flow of le ss than 12 mi. per second. Urethral obstruction was presumed when examinati on revealed urethral angulation, tethering, narrowing or scarification. Imp aired detrusor contractility was diagnosed when detrusor pressure at maximu m urinary flow was less than 20 cm. water at maximum urinary flow of less t han 12 mi. per second. Results: After suprameatal transvaginal urethrolysis 13 of the 20 women (65 %) in urinary retention voided well and in 8 of the 12 (67%) with urgency s ymptoms resolved. Postoperative stress urinary incontinence developed in on ly 1 case. Conclusions: The success rate of suprameatal transvaginal urethrolysis to t reat urinary obstruction associated with anti-incontinence procedures compa res favorably to that of other described alternative approaches. The succes s rate in patients with definite urodynamic criteria for obstruction was no t significantly better than in those who underwent suprameatal transvaginal urethrolysis based on physical examination and clinical judgment. Preopera tive maximal urinary flow rate was associated with operative success (p = 0 .018), while preoperative post-void residual urine and maximum detrusor pre ssure failed to reveal a difference between operative success and failure.