Extraperitoneal laparoscopic removal of eroded midurethral sling: a new technique

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.

Approach to management of iatrogenic foreign bodies of the lower urinary tract following reconstructive pelvic surgery

PURPOSE

Evolving techniques and materials for pelvic reconstruction have resulted in corresponding increases in the risk of iatrogenic foreign bodies in the lower urinary tract and vagina. We review the presentation, management and outcomes of iatrogenic foreign bodies in the female lower urinary tract and vagina.

MATERIALS AND METHODS

We performed a retrospective review of the records of all women undergoing removal of lower urinary tract foreign bodies during a 9-year period. All patients underwent a structured evaluation including history, physical examination, ancillary testing as indicated and subjective symptom appraisal.

RESULTS

A total of 85 women were identified, of whom 48 had vaginal, 40 had lower urinary tract, and 3 had concomitant vaginal and lower urinary tract excision of foreign material. Of the lower urinary tract cases the foreign body was located in the urethra in 12, bladder neck in 10, bladder wall in 18 and trigone in 3, while the remainder of the cases was vaginal in location. Aggressive surgical management aimed at removal or debulking of the exposed foreign body necessitated cystorrhaphy/partial cystectomy (20), urethroplasty (18) and fistula repair (3). Of the patients with vaginal excision 36 (75%) reported cure (of presenting symptoms), 10 (20.8%) reported improvement and 2 were unavailable for followup. Of the patients with lower urinary tract excision 21 (52.5%) reported cure, 14 (35%) indicated improvement and 5 were unavailable for followup.

CONCLUSIONS

In a complex group of women with vaginal or lower urinary tract foreign body extrusion, aggressive operative management resulted in high rates of subjective patient cure. Adequate assessment of newer reconstructive technologies is critical to assess the full impact of these complications.

Biomaterials in urinary incontinence and treatment of their complications

Biomaterials integrate with the anatomy and provide support to the weakened area. They are generally synthetic, but natural substances are also used. These substances are being increasingly used in stress urinary incontinence. This article discusses the various biomaterials, minimally invasive techniques, and recent advances for the treatment of female stress urinary incontinence. In addition, their complications and subsequent management are explored.

Transurethral mesh resection after urethral erosion of tension-free vaginal tape: report of three cases and review of literature

A rare complication after tension-free vaginal tape (TVT; including TVT-O) procedure is erosion of the tape through the urethral wall. In the literature, different methods to remove this intra-urethral tape are described. Most authors used the transvaginal approach with urethrotomy. In the cases described in this article, the transurethral approach is applied and proposed as the optimal method, being minimally invasive and less damaging to the urethral wall A transurethral catheter can be removed shortly after surgery to enable optimal tissue healing of the urethral mucosa.