Managing Complications after Midurethral Sling for Stress Urinary Incontinence

Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings

OBJECTIVE

To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal.

METHODS

We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009-2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed.

RESULTS

87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P = 0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P = 0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%).

CONCLUSION

Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.

Association between the Urinary Bladder Volume and the Incidence of "De Novo" Overactive Bladder in Patients with Stress Urinary Incontinence Subjected to Sling Surgeries or Burch Procedure

Aim. The aim of the study was to compare the incidence of "de novo" overactive bladder (OAB) after sling surgeries and Burch procedure and to analyze the effect of the preoperative bladder volume on the incidence of this condition. Methods. This prospective trial included 290 female patients with stress urinary incontinence (SUI) who were subjected to sling surgeries (TOT or TVT, n=170) or Burch procedure (n=120). Urodynamic testing was performed prior to the surgery and 6 months thereafter. The presence of OAB was diagnosed on the basis of subjective symptoms and urodynamic parameters. Results. The incidence of OAB 3 at 6 months postsurgery was the highest in patients who were subjected to the Burch procedure (14.2% and 17.5%, respectively). The incidence of OAB at 6 months turned out to be significantly higher in patients subjected to the Burch procedure with preoperative bladder volumes greater than 353 ml. We observed the significant postoperative decrease in the bladder volume of women who developed this complication following the Burch procedure. Conclusions. Among surgeries for stress urinary incontinence, Burch procedure is associated with the greatest risk of overactive bladder development. Probably, one reason for the higher incidence of overactive bladder after Burch procedure is the intraoperative reduction of the urinary bladder volume.

Transvesical laparoendosopic single-site surgery as a valuable option to remove eroded materials from the bladder: single-center experience and a review of the literature

Introduction

Currently, polypropylene materials are used widely for the treatment of various urogynecologic disorders. This type of treatment can be complicated, although rarely, with erosions of the polypropylene implants into the bladder or the urethra. There is no established treatment for such complications. We present our experience in transvesical laparoendoscopic single-site surgery (T-LESS) removal of eroded materials, and a review of the literature in this field.

Materials and methods

From June 2015 to May 2017 eight females, with an average age of 66.5 years (range 55–80 years), were referred to our Center because of the erosion of polypropylene material in the bladder, after anti-incontinence or pelvic organ prolapse treatment. Patients were diagnosed with ultrasound and cystoscopy. Seven bladder erosions and one bladder and urethral penetration were found. Patients were qualified for removal with the T-LESS approach. The Tri-Port + disposable set and standard laparoscopic instruments were used. The eroded materials were dissected and cut away, and the defects of the bladder wall were closed with barbed sutures. The peri-operative efficacy and safety of the method were assessed, and the patients were scheduled for follow-up visits at 6 weeks and every 3 months thereafter. The patients were offered a cystoscopic exam during the 7–10 month period after the operation.

Results

The procedures were completed successfully in all patients. No blood loss or complications were observed. The mean operative time was 54.5 min, and the average hospital stay was 30 h. During a follow-up at 11 months, all patients were cured, except for one who presented urethral erosion.

Conclusions

The T-LESS technique for removal of eroded meshes is a safe and effective method. The precise access to the bladder minimizes morbidity, and suturing the bladder wall defects may reduce the risk of recurrence.

Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder

INTRODUCTION

The mid-urethral sling (MUS) procedure is the gold-standard for the surgical treatment of stress urinary incontinence (SUI). Urethro-vesical sling exposure is one of the most serious complications of this procedure. We describe the treatment and follow-up of 18 patients with bladder or urethral sling exposure.

PATIENTS AND METHODS

This single-center, retrospective study assessed the diagnosis and management of MUS penetrating the lower urinary tract in 18 women. The lesions included were classed as 4B, T3-4, S3 according to the international classification of complications related to the insertion of prostheses. Diagnosis was confirmed by flexible urethro-cystoscopy. The patients were treated surgically. In all cases, the aim was to remove all synthetic materials eroding the bladder or urethra. The patients were reassessed 6 weeks after the procedure, and functional urologic sequelae were treated. Urologic symptoms were evaluated using the USP questionnaire and urologic comfort was assessed using the Contilife questionnaire.

RESULTS

Seven MUSs were retro-pubic and 11 were trans-obturators. The material was 11 polypropylene macroporous monofilament, four polypropylene silicone coated and three non-available. There were six cases of urethral sling exposure, nine cases of bladder sling exposure, and three cases of urethral and bladder sling exposure, including five complicated cases of lithiasis and one urethra-vaginal fistula. Thirteen patients underwent one surgical procedure, four underwent two, and one underwent five procedures. Seven patients received a Martius flap. Three surgical approaches were necessary: (i) vaginal approach; (ii) urologic (urethral and suprapubic) cystoscopy approach; and (iii) laparoscopy approach. Median follow-up time was 34.5 months. At the end of follow-up, 17/18 patients had no sling exposure from the MUS, and 12/13 patients were considered comfortable from a functional urologic viewpoint.

CONCLUSION

Our study showed that surgery could treat urethro-vesical sling exposure. Three surgical approaches may be necessary. Controlled cystoscopy is vital to confirm healing due to the recurrences of sling exposure in our study.

On the Stiffness of the Mesh and Urethral Mobility: A Finite Element Analysis

Midurethral slings are used to correct urethral hypermobility in female stress urinary incontinence (SUI), defined as the complaint of involuntary urine leakage when the intra-abdominal pressure (IAP) is increased. Structural and thermal features influence their mechanical properties, which may explain postoperative complications, e.g., erosion and urethral obstruction. We studied the effect of the mesh stiffness on urethral mobility at Valsalva maneuver, under impairment of the supporting structures (levator ani and/or ligaments), by using a numerical model. For that purpose, we modeled a sling with “lower” versus “higher” stiffness and evaluated the mobility of the bladder and urethra, that of the urethrovesical junction (the α-angle), and the force exerted at the fixation of the sling. The effect of impaired levator ani or pubourethral ligaments (PUL) alone on the organs displacement and α-angle opening was similar, showing their important role together on urethral stabilization. When the levator ani and all the ligaments were simulated as impaired, the descent of the bladder and urethra went up to 25.02 mm, that of the bladder neck was 14.57 mm, and the α-angle was 129.7 deg, in the range of what was found in women with SUI. Both meshes allowed returning to normal positioning, although at the cost of higher force exerted by the mesh with higher stiffness (3.4 N against 2.3 N), which can relate to tissue erosion. This finite element analysis allowed mimicking the biomechanical response of the pelvic structures in response to changing a material property of the midurethral synthetic mesh.

Laparoscopic Burch urethropexy at time of mesh sling removal: A cohort study evaluating functional outcomes and quality of life

AIM: To theorize that performing a laparoscopic Burch urethropexy at time of sling removal would significantly decrease subjective symptoms of stress urinary incontinence (SUI) and improve patient satisfaction.

METHODS: Women who underwent a combined sling removal and laparoscopic Burch procedure between 2009 and 2014 were matched via age and sling-type in a 1:2 ratio to women who only underwent a sling removal. Those who underwent surgery within 6 mo of data collection were excluded from the study, as were women who underwent multi-stage surgery. Preoperative assessment for both groups included a focused clinical exam with or without functional testing and questionnaires including urogenital distress inventory-6 (UDI-6) and incontinence impact questionnaire-7 (IIQ-7) per the standard clinical practice. All non-exempt women were sent a questionnaire that included UDI-6 and IIQ-7 in addition to standard follow-up questions. Research staff contacted participants via email, mail, and telephone using the same questionnaire template and script. Data was analyzed by using χ² test for categorical data, and Student’s t test and Wilcoxon Rank Sum test for continuous data. The measure of effect was determined by logistic regression analysis.

RESULTS: A total of 48 women out of 146 selected patients were successfully recruited with n = 22 in the Burch cohort and n = 26 in the control cohort. The mean age was 54.7 ± 7.8 years and mean body mass index was 22.0 ± 13.9 kg/m². The majority of patients were Caucasian (73.3%), postmenopausal (91.1%), nonsmokers (57.9%), with a history of hysterectomy (81.4%). Six nineteen point six percent of women presented after at least 2 years from placement, which was significantly more common in the Burch cohort. Pain was the most common chief complaint (64.4%) in both groups at the time of initial presentation, and 78.9% of women reported concomitant urinary incontinence. There was no significant difference in pre-operative UDI-6 and IIQ-7 scores between the two cohorts. However, the change in UDI-6 score postoperatively was significantly improved in the Burch cohort with an average drop in score of 28.41 points compared to a decrease of 4.01 points in the control group (P = 0.02, 95%CI: 3.84 to 44.97). Although not statistically significant, the Burch cohort was 58% more likely to show an overall improvement in their score after surgery and 40% more likely to meet the minimal important difference of 11 points (RR = 1.58, 95%CI: 0.97 to 2.57; RR 1.40, 95%CI: 0.79 to 2.46). The difference in IIQ scores was nonsignificant. There was no significant difference in blood loss, complications, or postoperative pain or dyspareunia.

CONCLUSION: Performing a Burch urethropexy during sling removal does not increase complication rates and results in a significant change in validated symptom-related quality of life scores.

Concomitant Laparoscopic Burch Urethropexy and Combined Vaginal-Laparoscopic Mesh Sling Removal (x2) for Pain and Persistent Stress Urinary Incontinence

Although midurethral mesh tape slings are considered the standard of care in the treatment of female stress urinary incontinence (SUI), complications such as pain, dyspareunia, or erosion are known to occur in addition to persistent incontinence. The management of these types of mesh sling complications can be very complex, especially when the pain is not just isolated to the vagina but extends into other areas, such as the abdomen which requires a much more extensive dissection. Additionally, if a mesh sling needs to be removed, the patient will most likely have a return of her SUI that often necessitates subsequent treatment. Vaginal and/or laparoscopic removal or revision of mesh tape slings should be considered in patients presenting with complications such as vaginal pain, abdominal pain, dyspareunia, or urinary obstructive symptoms. In those patients who demonstrate persistent SUI, concomitant laparoscopic Burch urethropexy can be considered and can safely be performed at the time mesh removal. In this case report we present a patient who required a dual-approach removal of two painful midurethral slings in addition to concomitant treatment of persistent SUI with a laparoscopic Burch urethropexy procedure.

The Single-Incision Sling to Treat Female Stress Urinary Incontinence: A Dynamic Computational Study of Outcomes and Risk Factors

Dynamic behaviors of the single-incision sling (SIS) to correct urethral hypermobility are investigated via dynamic biomechanical analysis using a computational model of the female pelvis, developed from a female subject's high-resolution magnetic resonance (MR) images. The urethral hypermobility is simulated by weakening the levator ani muscle in the pelvic model. Four positions along the posterior urethra (proximal, midproximal, middle, and mid-distal) were considered for sling implantation. The α-angle, urethral excursion angle, and sling-urethra interaction force generated during Valsalva maneuver were quantitatively characterized to evaluate the effect of the sling implantation position on treatment outcomes and potential complications. Results show concern for overcorrection with a sling implanted at the bladder neck, based on a relatively larger sling-urethra interaction force of 1.77 N at the proximal implantation position (compared with 0.25 N at mid-distal implantation position). A sling implanted at the mid-distal urethral location provided sufficient correction (urethral excursion angle of 23.8 deg after mid-distal sling implantation versus 24.4 deg in the intact case) with minimal risk of overtightening and represents the optimal choice for sling surgery. This study represents the first effort utilizing a comprehensive pelvic model to investigate the performance of an implanted sling to correct urethral hypermobility. The computational modeling approach presented in the study can also be used to advance presurgery planning, sling product design, and to enhance our understanding of various surgical risk factors which are difficult to obtain in clinical practice.

Obturator Nerve Injury: An Infrequent Complication of TOT Procedure

Transvaginal mid-urethral slings have become the most preferred surgical treatment option for female stress urinary incontinence. However, various complications have been reported for these operations occurring especially during penetration of the retropubic space. It can negatively affect patient's quality of life. Early treatment increases the chance of complete normalization of the functions. In this case report we presented a case of obturator nerve damage that was diagnosed and treated at early stage after TOT operation.

Delayed intravesical mesh erosion in a midurethral sling following further mesh-augmented pelvic prolapse surgery

Intravesical mesh erosion and extrusion have been reported as devastating late complications of synthetic suburethral sling placement for the treatment of stress urinary incontinence. We report a case of a female patient with intravesical mesh erosion from a sling suspension that developed 4 years after primary prolapse surgery with mesh reinforcement. Intravesical mesh erosion was observed ultrasonographically and confirmed through cystoscopy. We excised the mesh via a vaginal approach and repaired both bladder mucosa and vaginal wall. As of this writing, the patient has been symptom-free for the past year post-surgery. Long-term follow-up is recommended in such cases. Anti-incontinence surgery followed by primary prolapse surgery could potentially jeopardize the former. Complications may arise several years later so long-term follow-up is essential. Ultrasonography is an effective tool in evaluating mesh morphology and detecting intravesical mesh erosion.

Endoscopic transurethral resection of urethral mesh erosion with the use of a pediatric nasal speculum

BACKGROUND

A rare but challenging complication of midurethral slings is erosion of mesh tape through the urethral wall.

CASES

In this report, we describe two cases in which a pediatric nasal speculum provided exposure for transurethral resection of eroded mesh. Exposure was sufficient for complete mesh resection endoscopically as well as with use of traditional surgical instruments. Since having surgery there has been no recurrence of mesh erosion and the irritative voiding symptoms have resolved.

CONCLUSION

Urethral mesh erosion can be managed from a transurethral approach. Furthermore, use of a pediatric nasal speculum improves visualization and efficiency.