Satoru Takahashi M.D., Ph.D., Department of Urology, Nihon University School of Medicine, 30-1 Oyaguchi-Kamimachi, Itabashi, Tokyo 173-8610, Japan. Email: email@example.com
We have experienced two cases of intravesical transobturator tape (TOT) tape successfully removed by laparoscopic transvesical procedure. Patient 1 was a 67-year-old woman complaining of irritative symptoms of the urinary bladder. In another hospital she had undergone anterior corporrhaphy and a TOT procedure to treat a cystocele and stress urinary incontinence (SUI) 17 months before the initial consultation. A cystoscopy revealed tape extrusion and adherent calculi at the 4 to 5 O'clock position of the bladder neck. After filling the bladder with carbon dioxide, three 5-mm ports were placed in lower abdomen directly into the bladder. The tape extruding from the bladder muscle layer was completely excised, and extirpated with the adherent calculi. The bladder mucosa and muscle layer were continuously sutured using 4-0 Vicryl (Ethicon Inc., Somerville, NJ, USA). The port entry sites were closed under direct vision using 4-0 Vicryl. SUI recurred 15 months later and a second TOT surgery was performed. Neither SUI nor mesh extrusion have been observed during the 18 months following the second TOT. Patient 2 was a 74-year-old woman. She consulted our hospital for the removal of an intravesically extruded tape and adherent calculi. She had undergone a vaginal hysterectomy and TOT surgery for uterine prolapse and SUI at another hospital 3 years before her visit. A cystoscopy revealed tape extrusion and adherent calculi on the right bladder wall. We performed an endoscopic transvesical extirpation of the intravesical foreign bodies in a same manner described below. There has been no recurrent SUI or mesh erosion during the 18-month follow up.
Currently, the transobturator tape (TOT) procedure is commonly employed as a surgical procedure for stress urinary incontinence (SUI) in women because of its low incidence of complications such as organ injuries.1 However, several reports have appeared describing erosive mesh with adherent stones after a TOT procedure. These may occur when needles are inadequately passed through the bladder wall during TOT surgery, or when the tape on tension erodes into the bladder after the surgery. Apart from open surgery, a laparoscopic approach may be able to resolve these problems.
In this study, we report on the laparoscopic transvesical removal of intravesical tape and adherent calculi following TOT surgery.
The patients were placed under general and epidural anesthesia in a low lithotomy position. Initially, a cystoscopy was performed to confirm tape extrusion and adherent calculi (Fig. 1). A sufficient volume of saline was infused into the urinary bladder to dilate it. The anterior bladder wall was punctured using an 18G needle under the guide of transabdominal ultrasound and a 3-0 nylon thread was passed through the needle hole into the bladder. Then an Endo Close (Covidien, Mansfield, MA, USA) was inserted to bladder 2-cm caudal from the puncture site, and the thread was led from the abdominal wall for the fixation of the bladder. Subsequently, the bladder was transurethrally dilated with carbon dioxide, and three 5-mm step ports, including a camera port, were placed on the lower abdomen into the bladder (Fig. 2). The pneumovesical state was maintained at 8–12 mmHg. Using exfoliation and Mayo forceps, the bridge-like tape was pulled out from the bladder mucosa and completely dissected from the bladder muscle layer (Fig. 3). The tape and adherent calculi were removed from the urethra using forceps. The bladder mucosa and muscle layer were continuously sutured using 4-0 Vicryl (14 cm) (Ethicon Inc., Somerville, NJ, USA) (Fig. 4). The ports were removed, and the bladder wall and skin of port entry site were closed under direct vision with 4-0 Vicryl. An 18-Fr Foley catheter was placed in the bladder, and the surgery was completed. In the first patient, the operation time was 150 min, and the blood loss was 10 mL. In the second patient, the operation took 142 min and blood loss was 40 mL. The Foley catheters were removed 7 days after surgery. The calculi consisted of magnesium or ammonium phosphate. In the first patient, SUI recurred 15 months after surgery, and a second TOT procedure was selected. There has been no recurrent SUI or tape extrusion during the 18-month follow-up in either patient.
In TVT surgery, the needle passes along the posterior surface of the pubic bone. Therefore, there is a possible risk of bladder perforation. In contrast, in the TOT procedure there is little risk of bladder injury and routine intraoperative cystoscopy is not necessary.1,2 However, several patients have experienced urinary tract injury after TOT surgery,3–6 which may be derived from needle injury or late onset tape erosion.
Here, we report successful repairs of intravesical mesh extrusion after TOT surgery using laparoscopic transvesical procedure with mucosal sutures. Several studies have reported the transurethral removal of the intravesical tape and adherent calculi.7–9 The transurethral approach is an option of the treatment. However, Oh et al. reported that one of 14 patients who underwent a simple transurethral resection experienced a recurrence of mesh extrusion and stone formation.7 Rosenblatt et al. indicated the need for a complete removal of the intravesical mesh, including the part in the bladder wall. They placed an endoscope using a suprapubic cystostomy, and extirpated the extruded tape transurethrally.10
So far no studies comparing the outcomes of these two methods have been reported. However, we believe that the suture of the wound after the removal of a foreign body may be more suitable for steady repair than simple removal. In particular, surgery for case with postoperative complications should be more reliable than for naïve case. Therefore, we employed a pneumovesical endoscopy to ensure suture of mucosal and muscle layers of the bladder.
Recently, Ingber et al. reported their experiences in laparoscopic, single-port, transvesical surgery. They emphasized its advantage in terms of its minimal invasiveness.11 Indeed, a single port surgery is promising in the future. However, as these authors also mentioned, a mucosal approximation following the tape dissection and removal is required for hemostasis and prevention of subsequent stone formation. A certain distance in-between each forceps may facilitate mucosal suture especially when the intravesical foreign body is located away from the bladder neck. Using the technique we have presented here, a continuous suture of the bladder mucosa and muscle layer is easy to perform.