Vaginal approach to postsurgical bladder outlet obstruction

Bladder outlet obstruction resulting in voiding dysfunction following anti-incontinence procedures can be a disappointing outcome for both patient and surgeon. When stress incontinence is replaced by lower urinary tract symptoms (LUTS) such as frequency, urgency or urge incontinence, difficulty voiding, or urinary retention, the patient may have more severe complaints than at initial presentation. It is a challenging task for the clinician to decide what if any action to take and when to take it and by what approach. Several considerations are the type of anti-incontinence procedure, postoperative physical findings, the patient's degree of bother, and any addition testing that may be performed. Recent work has focused on clarifying the etiology and incidence of this condition, as well as providing new definitions on bladder-outlet obstruction in women. In addition, effective, less invasive ways of treating this condition have been described. The prevailing doctrine is not to make a bad situation worse and to find the simplest solution that produces the least anxiety for the patient. The vaginal approach to sling incision and urethrolysis is appealing for this reason. This chapter discusses the incidence and etiology of postsurgical obstruction, the diagnostic evaluation, and the current management and treatment for this condition, with specific emphasis on the vaginal approach.