Unrecognized bladder perforation with mid‐urethral slings

Abstract

Study Type – Therapy (case series) Level of Evidence 4OBJECTIVETo present a series of women with late presentation of mid‐urethral synthetic slings perforating the bladder and their management, this is rare but can lead to significant morbidity with medico‐legal consequences.PATIENTS AND METHODSWe retrospectively reviewed the case notes of nine women with urinary symptoms referred to our unit for further investigation after synthetic mid‐urethral sling placement.RESULTSThe women presented between 8 weeks and 18 months after initial sling placement. Eight patients underwent a tension‐free vaginal tape insertion via the retropubic route and one patient had an ‘outside‐in’ obturator sling with the I‐Stop device (CL Medical, Lyon, France). The frequencies of presenting symptoms were: dysuria in six; recurrent urinary tract infection in four; frequency and urgency in four and pelvic pain in two. Seven of the nine women developed bladder calculi on the exposed sling material, all of which were visible on plain X‐ray. In six women, perforations were present at more than one site; in three urethral perforation had occurred together with an anterolateral bladder injury and in the remaining three there was bilateral bladder perforation. Initial management included cystoscopy and cystolithopaxy followed by transurethral resection (TUR) of the visible prolene mesh into the detrusor muscle. One woman required two TURs to clear all the mesh. Two women required further open surgery to remove all of the remaining mesh, both for ongoing pelvic pain that resolved after revision surgery. All the women had resolution of symptoms but all had recurrent stress urinary incontinence after tape division/excision. We used a novel technique to remove intraurethral mesh using a nasal speculum urethrally and excising the tape under direct vision, where resection proved impossible due to poor endoscopic views, with significant risk of sphincter injury.CONCLUSIONSThe possibility of unrecognized tape perforation or erosion must be considered in women with persistent urinary symptoms, infection or pain after any form of mid‐urethral sling procedure. Bladder stones almost invariably develop if the exposed mesh has been present for >3 months. Most patients can be managed with endoscopic resection to remove all intravesical tape. Cystoscopy should remain a mandatory procedure together with any form of mid‐urethral sling placement but does not prevent unrecognized perforations in inexperienced hands.

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

“…[130] Some patients may need multiple TUR for complete mesh excision [Table 15]. [131] The possible complications of this approach include extraperitoneal bladder rupture and vesicovaginal fistula formation. [130] This technique is not recommended for urethral erosion, due to higher possibility of incomplete removal and urethral perforation.…”

Role of endoscopic management in synthetic sling/mesh erosion following previous incontinence surgery: a systematic review from European Association of Urologists Young Academic Urologists (YAU) and Uro-technology (ESUT) groups

“…Endoscopic management of eroded foreign body (FB) can be performed by intravesical resection of the mesh with electrode loop via a resectoscope or laparoscopic scissors [17][18][19][20], although it has been increasingly popular to use transurethral endoscopic resection using holmium laser [21]. These are minimally invasive approaches to a complex clinical problem.…”

Laparoendoscopic single-site transvesical removal of mid-urethral polypropylene sling eroded into the bladder

“…Erosion of sling materials into the lower urinary tract is an uncommon but known complication after pubovaginal sling placement. Urethral erosion is reported at a rate from 2.7% to 33% and bladder erosion is much less common with incidences ranging from 0.5% to 0.6%, but these data are obtained mainly from the literature on TVT or other well-described techniques [3,[16][17][18]. There are no reliable analyses of so-called "hand-made" tapes although this kind of procedure is likely performed in many countries.…”

“…Nevertheless, it requires the placement of 3 or more trocars, each creating its own incision [7,19]. The endoscopic procedures seem to be simpler but the inconvenience in using manipulators often leads to prolonged intervention time or even failure [18,20].…”