[The Martius flap in stress urinary incontinence treated by suburethral sling]

Urethral exposure of mid-urethral sling: diagnosis, management and functional outcomes

OBJECTIVES

To identify symptoms leading to urethral mesh exposure diagnosis, describe the surgical management and evaluate post-operative functional and urodynamic outcomes.

METHODS

Retrospective observational monocentric study of 15 patients treated by mid-urethral sling removal for urethral exposure, between December 2005 and February 2021, in a pelviperineology centre.

RESULTS

Fifteen patients were included. The mean time to diagnosis of urethral exposure was 43 months. This diagnosis delay was caused by a non-specific symptomatology. Surgical management consisted of partial removal of the eroded mid-urethral sling fragment by vaginal approach in all cases, with low peri-operative morbidity. At three months follow-up, 87% of the patients had stress urinary incontinence versus 54% at two years. 13 patients had a urodynamic assessment after their mid-urethral sling removal, they all had sphincter insufficiency with a urethral closure pressure lower than 30 cm H₂O. Nine patients underwent a second urinary incontinence management procedure, leading to 77% of complete remission and 23% of partial improvement.

CONCLUSION

Clinical presentation of urethral erosion after mid-urethral sling is heterogeneous. Surgical management is complex; after a good preoperative evaluation, a two-step management strategy including minimally invasive mid-urethral sling removal and treatment of recurrent urinary incontinence leads to good results with 77% of patients cured. Sphincter insufficiency is one of the mechanisms that may explain the high rate of stress urinary incontinence after urethral mesh erosion surgery.

[Surgical management of suburethral sling complications and functional outcomes]

OBJECTIVES

To identify various clinical presentation leading to the diagnosis of mid-urethral sling (MUS) complications and to analyze the functional outcomes after surgical management of these complications.

METHOD

Retrospective observational monocentric study of all patients treated by MUS section or removal, between December 2005 and October 2019, in a pelviperineology centre.

RESULTS

During this study, 96 patients were included. MUS complications surgically managed were vaginal mesh exposure (48 %), urethral mesh exposure (17 %), bladder mesh exposure (10 %); dysuria (30 %), pain (6 %), and infection (3 %). The mean time to diagnosis was 2 years. This diagnosis delay was caused by a non-specific and heterogeneous symptomatology. Surgical management consisted in MUS partial removal (79 %) and MUS simple section (21 %) with low perioperative morbidity. At three months follow-up, 36 patients (53 %) had stress urinary incontinence (SUI), including 13 (19 %) de novo (meaning no SUI before MUS section/removal) and 19 (28 %) had overactive bladder, including 9 (13 %) de novo. Half of the patients with SUI after MUS section/removal were able to be treated by a second MUS with a success rate of 83 % at 3 years.

CONCLUSION

Clinical presentation of MUS complications is heterogeneous. Surgical treatment was associated with low morbidity in our study. Post-operatively, half of the patients had SUI and a second MUS was a relevant treatment option after proper evaluation.

LEVEL OF EVIDENCE

4.

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.

How and why to take a Martius labial interposition flap in female urology

The Martius modified labial fat pad flap at nearly 90 years old is still very much part of the modern vaginal surgeon’s armamentarium. Here we describe this straightforward and adaptable technique, the avoidance of pitfalls, its advantages and uses in vaginal surgery, and outcomes both short and long term. Specifically patient reported outcomes related to scar perception and sexual function are explored.

Martius graft for TOT extrusion: a case series

INTRODUCTION

The management of mid-urethral tape extrusion is inconsistent. We believe that we present here the first case series detailing the use of the Martius graft for trans-obturator tape (TOT) extrusion.

METHODS

Five women had a Martius graft for TOT extrusion. Data were obtained retrospectively from case notes and a review postoperatively to investigate the results in the short and intermediate term.

RESULTS

All extrusions were greater than 1 cm in diameter and situated between the midline and the lateral vaginal sulcus. In 3 women the tape extrusion was discovered at 6-12 weeks postoperatively and 2 presented with symptoms again after 12 months. Following the Martius graft, there was no ipsilateral recurrence of tape extrusion or exposure. Postoperatively, 2 women received oral antibiotics. Two women developed de novo sexual problems, which had resolved at follow-up.

CONCLUSIONS

It is promising that all the tape extrusions were successfully treated with a Martius Graft, thus preserving tape function. There was a high incidence of minor complications initially, but there was minimal long-term morbidity and no cosmetic dissatisfaction. We believe that testing this proposition in a larger case series will provide better evidence.