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(9) Recurrent Prolapse

Recurrent prolapse may occur in the setting of almost any vaginal repair Where the anatomic axis of the vagina is changed . This may result in a change in the dynamic forces of where the intra abdominal pressure is transmitted and may cause exacerbation of preexistent prolapse.

Therefore, one must aggressively seek to identify any moderate to severe degrees of prolapse that may potentially worsen with time . A dynamic MRI evaluation of the pelvic floor in patients with high grade prolapse and have found unrecognized pelvic floor pathology in a significant minority. We then approach these patients with the intent to identify and correct the pathology in order to prevent recurrent prolapse in the future. If recurrent prolapse occurs, one must decide if it is severe or symptomatic enough to require operative management.

(10) De novo urgency incontinence

De novo bladder instability and urgency incontinence is a well known complication of anti – incontinence surgery. Most often, symptoms were present preoperatively and become more pronounced in the postoperative period as the accompanying SUI has been treated. This is often temporary and resolves over time. Several patients however, develop new-onset de novo bladder instability causing them to be surgical failures . The reported incidence of this complication varies considerably but may be as high as 28.5 %. The etiology of this is unclear but may be related to unrecognized preoperative detrusor instability masked by severe sphincteric incompetence or the creation of sub clinical bladder outlet obstruction.

The treatment is primarily medical in nature including behavioral modification, anticholinergics and electrical stimulation. In isolated cases, augmentation cystoplasty can be considered.

(11) Urinary Outlet Obstruction

Although all the anti – incontinence procedures discussed above are non – obstructive by design, the potential for postoperative bladder outlet obstruction exists and has been reported in the literature even in well – performed procedures. Obstruction occurs usually in the setting of improper suture placement as discussed above or due to overzealous elevation of the bladder neck and proximal urethra while tying the suspending sutures. Sutures used for support of trans vaginal needle suspensions or slings of any variety should never be tied down under tension. This may create postoperative outlet obstruction resulting in urgency, frequency, large post- void residual and possible even urinary retention. The knot should be laid down onto the abdominal wall fascia under absolutely no tension. Pulling up to the sutures as they are tied is unnecessary to produce urinary continence. As described above the goal of anti incontinence surgery is not to produce obstruction but rather to create a valvular mechanism in suspension surgery and improve coaptation during sling surgery. We place a cystoscope sheath per urethra and incline it to 30 degrees to the horizontal prior to tying the suspending sutures. This angle re approximates the native position of the vesico urethral junction in the nulliparous female and prevents excessive elevation of the proximal urethra during tying of the sutures.

Finally, in some cases, postoperative development of a cystocele may cause bladder outlet obstruction. Failure to recognize and correct coexistent pelvic prolapse during an anti-incontinence operation may result in an enlarging cystocele postoperatively, which kinks at the level of the bladder outlet in the location of the suspension sutures. Provided, that adequate bladder outlet support was obtained at the time of bladder neck suspension, simple repair of the cystocele will result in the return of normal voiding function as well as the maintenance of urinary continence.

Outlet obstruction in the female is a difficult diagnosis. The most helpful finding is a postoperative change in voiding symptoms in the setting of an increased post void residual. These patients may present with the postoperative onset of new irritative voiding symptoms including urgency, frequency and urge incontinence. This should be differentiated from the well suspended patient with some preoperative baseline irritative symptoms which either remain or perhaps are somewhat exacerbated by the surgery. The vast majority of these patients will have resolution of their irritative symptoms with time. It is also common for patients with pure stress incontinence preoperatively to have some degree of urgency and frequency postoperatively due to the inherent nature of pelvic surgery and perivesical inflammation. These patients are treated symptomatically with anticholinergic agents until the symptoms resolves usually within 1-2 months.

Commonly, female patients with outlet obstruction will not exhibit the high pressure low flow findings on urodynamics commonly seen in the obstructed male. Voiding cystourethrography may demonstrate urethral kinking or perhaps an over suspended urethra and bladder neck with the bladder neck elevated to an unphysiologically high retropubic position. Conversely, an obstructed urethra may be in good anatomic position but is nonetheless fixed in position and unable to funnel and open during a bladder contraction.

The treatment of these patients includes intermittent catheterization and anticholinergics initially in refractory cases urethrolysis and re suspension may be necessary and has been shown to produce good result in 65%-93% of cases.

(12) Vaginal Narrowing/stenosis

Excessive excision of the vaginal wall may lead narrowing of the vagina and stenosis. Additionally, excessive plication of tissue may lead ridges development and these often become painful and tender. We use several steps to prevent these very avoidable complications. During cystocele, or entrocele repairs when excess vaginal tissue is excised one must be cognizant of the amount of tissue to be removed. We use a haney retractor to facilitate identification of vaginal depth, adjacent structures, and avoidance of over excision. Minimal tissue excision will help avoid narrowing; yet, similarly approximation of tissues too widely can cause the same result. One can avoid painful ridges by creating a smooth repair in a symmetric fashion. In particular during rectocele repairs, we find it necessary to continuously reassess the location of the suture to prevent asymmetry. Placement of sutures too laterally in rectocele repair can cause pain from levator spasm and tenderness, therefore, one should re approximate the pre and para rectal fascia as opposed to levator musculature.