Which high bladder neck procedure has the lowest risk of urinary retention?

Synthetic Midurethral Slings Have the Lowest Risk of Urinary Retention Among High Bladder Neck Procedures

Synthetic slings placed at the midurethra have significantly lower rates of urinary retention (3%) compared to synthetic slings placed at the bladder neck (9-10%) or autologous fascial slings (5-8%) 1.

Comparative Retention Rates by Procedure Type

Based on the American Urological Association (AUA) guidelines, urinary retention rates (lasting longer than 1 month or requiring intervention) vary significantly among different high bladder neck procedures:

Sling Procedures:

• Synthetic midurethral slings: 3% retention rate (both with and without concurrent prolapse treatment) 1
• Synthetic slings at bladder neck without bone anchors: 9% without prolapse treatment, 10% with prolapse treatment 1
• Autologous fascial slings without bone anchors: 8% without prolapse treatment, 5% with prolapse treatment 1
• Vaginal wall slings with/without bone anchors: 2-5% retention rates 1

Suspension Procedures:

• Burch suspension: 3% without prolapse treatment, 1% with prolapse treatment 1
• Laparoscopic suspension: 4% without prolapse treatment, 2% with prolapse treatment 1
• Open retropubic suspension: 4% without prolapse treatment, 1% with prolapse treatment 1

Clinical Implications and Decision-Making

The significant difference in retention rates between synthetic slings placed at the midurethra versus those placed at the bladder neck was specifically highlighted as an important finding by the AUA guideline panel 1. This difference should guide surgical decision-making when considering high bladder neck procedures.

Risk Factors for Retention

When selecting a procedure, consider these factors that may increase retention risk:

• Pre-existing voiding dysfunction
• Concurrent prolapse repair (increases retention risk with some procedures)
• Advanced age
• Previous failed anti-incontinence procedures

Management of Post-Procedure Retention

If retention occurs following a high bladder neck procedure, options include:

• Conservative management with intermittent catheterization
• Sling revision/loosening
• Transurethral resection of overcorrected bladder neck (as a salvage procedure)

Transurethral bladder neck resection has been shown to be effective for managing chronic urinary retention after incontinence repair, with 65.5% of patients achieving cure and 23% showing improvement 2.

Pitfalls and Caveats

• Bone anchors: Procedures using bone anchors may have higher complication rates, including infection and sinus tract formation 3
• Synthetic materials: While midurethral synthetic slings have the lowest retention rates, they carry risks of erosion and extrusion (7% vaginal and 1% unknown) 1
• Laparoscopic approaches: While laparoscopic suspensions have acceptable retention rates, they may have higher ureteral injury rates (11%) compared to open procedures (1%) 1

When counseling patients about the risk of urinary retention after high bladder neck procedures, the evidence clearly supports synthetic midurethral slings as having the lowest risk of this complication while maintaining good efficacy for stress urinary incontinence.