Management of Urethral Lesions and Urethrovaginal Fistula Formation Following Placement of a Tension-Free Suburethral Sling: Evaluation From a University Continence and Pelvic Floor Centre

Abstract

Introduction The complication of tape erosion in the urethra following placement of a retropubic (TVT) or transobturator (TOT) tension-free suburethral vaginal sling or an accidental iatrogenic transurethral tape position can result in the formation of a urethrovaginal or vesicovaginal fistula. The objective of the investigation is the evaluation of the management of such rare complications. Patients and Methods Retrospective analysis of 14 patients who were treated for a urethral lesion or urethrovaginal fistula formation status post TVT/TOT placement between June 2011 and February 2018 in the Tübingen University Department of Gynaecology. Results As surgical therapy, 57.1% (n = 8) cases underwent vaginal fistula closure using a Martius flap of the labium majus and in 21.4% (n = 3) using a vaginal rotation skin flap. In 21.4% (n = 3), exclusively vaginal suture reconstruction of the urethra following excision of the tape running transurethrally or tape erosion was performed. 50% (n = 7) of the patients had lasting continence postoperatively without any further need for therapy. In 28.6% (n = 4), there was ongoing stress urinary incontinence, in 21.4% (n = 3) mixed urinary incontinence. Six of the 7 patients with persistent incontinence underwent new placement of a tension-free suburethral retropubic sling (TVT) an average of 8.8 months (5 – 13 months) postoperatively which was uncomplicated in all patients and achieved satisfactory continence. The 3 patients with mixed urinary incontinence and persistent urgency components additionally received anticholinergic medication. During the time period investigated, there were no long-term complications, in particular no recurrent fistulas. Conclusion The rare but relevant complications of a urethral erosion, transurethral tape position or urethrovaginal fistula formation status post TVT/TOT placement can be successfully managed via vaginal surgery. Persistent postoperative urinary incontinence with the need for a two-phase repeat TVT placement following sufficient wound healing must be preoperatively clarified.

Urethrovaginal fistula 11 years after a bone anchor sling using woven polyester and treatment with a Martius flap

“…Despite being an obsolete procedure, bone anchor sling using woven polyester can cause vaginal/urethral exposure and UVF long after the procedure. Even the present gold‐standard MUS using polypropylene mesh can cause similar complications 9,12 . Therefore, we should be cautious about UVF when patients complain of worsened incontinence after SUI surgery.…”

“…Even the present gold‐standard MUS using polypropylene mesh can cause similar complications. 9 , 12 Therefore, we should be cautious about UVF when patients complain of worsened incontinence after SUI surgery.…”

Urethrovaginal fistula repair with or without concurrent fascial sling placement: A retrospective review

“…Complication rates found in the literature range from 7 -75%, with a recurrence rate of 10 -33%. 7,8,21,22 The main limitation of our study is that our data are from a single-surgeon, single institution cohort. The interpretation of our data is limited, due to the rarity of UVF, by the small sample size, resulting in low statistical power.…”

Do we have adequate data to construct a valid algorithm for management of synthetic midurethral sling complications? ICI‐RS 2019

“…Removal of the vaginal portion of sMUS alone was performed in 160 women with urethral erosion, and no recurrent erosion was seen after 6 to 38 months of follow up, but recurrent SUI was noted in 50% to 59% 65–80 . Complete mesh removal (open or laparoscopic) was utilized in 75 patients, and no recurrent erosion was seen after 3 to 38.5 months of follow up and recurrent SUI was noted in 28.5% to 50% 66,69,71,76,80–82 .…”