clinical question - need your help!

[Becky Margulies]

hi guys, 

What would you do?

70 yo s/p Burch in 1980s, then developed urge incont, had Botox in 8/2014 and went into retention, still in retention 13 mos later, doing CIC. She can void up to 150mL, and does CIC 4-5 x a day, 1-3 x at night. She has UUI 1-2 x a day and rare SUI (only if "bladder too full").

On urodynamics, she had some detrusor contractions, her capacity was 259mL. 

To make matters worse, she also demonstrated SUI. 

On pressure-flow, she was only able to void 35mL (valsalva voiding). 

Also to make matters worse, she has an asymptomatic prolapse

POPQ

-2  0  -4

3   3   9

0   0  -6

My options as I see it:

1) try to do some kind of transvaginal urethrolysis (but why would this work if she had a Burch, and all the scar tissue would be retropubic?)

2) attempt open Burch reversal (remove sutures)

3) attempt LSC Burch reversal 

4) fix her (asymptomatic) prolapse (LSC SCH and SCP), since her POP might be exacerbating the retention, AND reverse the Burch - then she would surely have worse SUI, but I told her that there's NO WAY I would put in a TVT at the same time... if her SUI were much worse postop, I could do a staged TVT. 

Any ideas appreciated...

Thanks!

b

[Amy Park]

Are her urodynamics before or after botox?

Did she have retention before Botox?

If retention purely from Botox, I would continue CISC for a few more months before consider transvaginal urethrolysis (higher likelihood of getting into bladder)

Her prolapse seems pretty mild but you could also put in a pessary to see if prolapse reduction helps.

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[Becky Margulies]

urodynamics done today (13 months after botox) - i didn't do the botox (not that it matters), i inherited this patient from a urologist at another kaiser....

i've never seen someone in retention for more than 2-3 weeks after botox so this is kind of weird. and her burch was about 35 years ago. so the whole thing doesn't make much sense to me...

[Amy Park]

that is most definitely weird but I wouldn't be rushing in to do any of those other options. I had a patient post-Botox who was in retention for over a year as well and it eventually resolved.

Taking down a Burch either from up top or down below = high likelihood of cystotomy

it sounds like she has detrusor overactivity along with insufficiency and SUI but it's hard to tell since it's post-Botox

[Becky Margulies]

thanks amy! maybe i will try a pessary.... 

[Olga Ramm]

In fellowship we did vaginal urethrolysis after burch and even cut the Burch sutures transvaginally. 

You could consider this before doing an apical support procedure?

Sent from my iPhone

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[Becky Margulies]

Monica Richardson thinks she just has an atonic bladder which wouldn't respond to any type of urethrolysis... she did void pretty much 100% by valsalva on pressure flow (what little she did void) - at peak flow, Pdet was 8 and Pabd was 136. 

[Amy Park]

those are really hard cases to treat - may be due to long standing obstruction from Burch = bladder poops out

[Becky Margulies]

yeah it's a total rock & a hard place. and i hate operating on those.... she's a very nice lady and a retired RN - she really doesn't want to do CIC forever but that might be her only option if she has a completely denervated bladder

[Blair Washington]

I would definitely start with a pessary to see if that support impacts emptying.   No risk and may help you decide if prolapse repair is worthwhile.  I think vaginal urethral lysis is an interesting idea but I've never done it...what are u going to do? B

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[Katherine Sandhu]

How about interstim trial for non obstructive retention ( if prolapse not a factor), and for oab.......

--------------------------------------

Katherine Shaio Sandhu, MD

Fairfield County Surgical Specialists

Urogynecology and Pelvic Surgery

1351 Washington Boulevard

Stamford, CT 06902

Phone: 203-391-6620

Fax: 203-276-4525

[Cassandra]

I agree with pessary trial (but it won't be the answer probably) and a little more time.  You can't do anything about her other ex until her retention resolves. Unless it doesn't...

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[Becky Margulies]

Yeah I'm just kinda worried she has a totally denervated bladder. No surgery will help that! Though her sensory nerves are intact...