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- PATIENTS AND METHODS
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Since their introduction in 1995, mid-urethral slings for the treatment of female stress urinary incontinence have become widely adopted as a minimally invasive and effective treatment with low complication rates. Bladder perforation at the time of tape insertion is a well-recognized complication of the retropubic approach, and has been reported with the transobturator route. If recognized at the time of surgery, there seem to be few long-term consequences, although one study reported slightly increased rates of de novo urge and persistent urge incontinence [1,2]. In the short term, haematuria or prolongation of the duration of postoperative bladder catheterization may occur .
However, in the rare cases when this is unrecognized, intravesical sling material causes significant morbidity with medico-legal consequences. Here we report the management of nine such women who presented to our hospital.
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- PATIENTS AND METHODS
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Nine women presented between 8 weeks and 18 months after initial sling placement (median 8 months; Table 1; Figs 1–3). Eight patients had undergone a tension-free vaginal tape (TVT) insertion via the retropubic route and one patient had an ‘outside-in’ obturator sling with the I-Stop device (monofilament macroporous polypropylene, CL Medical, Lyon, France). They most common complaint was of dysuria, often associated with recurrent UTIs or irritative symptoms. Seven women had developed bladder calculi on the exposed sling material, all of which were visible on plain radiographs (Fig. 4). Six women had more than one site of urinary tract perforation; three were bilateral bladder injuries and three involved a urethral perforation and an antero-lateral bladder injury.
Table 1. The patients’ characteristics, presentation and cystoscopic findings
|Patient||Age, years||Operative approach||Months to diagnosis||Presenting symptoms||Cystoscopic findings|
|1||50||Retropubic TVT||4||Dysuria, frequency, urgency||Bilateral encrusted intravesical tape|
|2||38||Retropubic TVT||2||Dysuria, frequency, urgency||Tape spanning bladder on left (Fig. 1)|
|3||69||Retropubic TVT||9||Recurrent UTI, pelvic pain||Right sided tape with 2 adherent bladder stones|
|4||66||Retropubic TVT||12||Dysuria, frequency, urgency||Urethral and encrusted bladder tape (Fig. 2)|
|5||75||Retropubic TVT||4||Dysuria, recurrent UTI||Bilateral intravesical tape and stones|
|6||70||Retropubic TVT||17||Recurrent UTI||Bilateral encrusted intravesical tape.|
|7||55||Retropubic TVT||8||Dysuria, frequency, urgency||Urethral and encrusted bladder tape (Fig. 3)|
|8||72||Retropubic TVT||18||Recurrent UTI||Visible calcified edge of mesh|
|9||49||Outside-in Obturator I-Stop||6||Dysuria, pelvic pain||Urethral and encrusted bladder tape|
All the women with intravesical sling material first underwent endoscopic cystolitholapaxy and transurethral resection (TUR) of the visible mesh down to detrusor muscle. Using monopolar diathermy, sufficient heat could only be applied to the mesh when it or part of the resection loop was in contact with bladder tissue, allowing completion of the diathermy circuit. The resection site healed with scarring, although one woman required a second TUR to clear all the visible mesh. After endoscopic clearance of all intravesical mesh, two women had ongoing pelvic pain. These women underwent further open surgery via a retropubic, extraperitoneal approach to remove all remaining intrapelvic mesh, with subsequent resolution of their symptoms.
Three women had tape visible in their urethras as well (Fig. 5). Endoscopic resection of this tape was impossible due to poor endoscopic views and the significant risk of sphincter injury. We therefore used a novel technique to remove the intraurethral mesh using an illuminated nasal speculum, which was gently passed per urethrally and allowed excision of the tape using sharp dissection under direct vision (Fig. 6).
These manoeuvres were our choice as instrumentation and expertise was easily available, and the procedures were sufficient to resolve the patients’ presenting symptoms. However, all developed recurrent stress urinary incontinence after tape division or excision. Six women have since undergone a further mid-urethral sling insertion, with successful outcomes, although three are currently declining further surgery.
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Bladder perforation is one of more common complications of the retropubic approach, but rarely encountered using the transobturator route. In a meta-analysis of complications reported in 1854 patients, bladder perforation was most common, occurring in 3.5% of retropubic sling insertions and in 0.2% of procedures using the transobturator route , although incidences as high as 24% have been reported . Although it has been stated that bladder perforation only occurs during the ‘outside-in’ technique [2,5], there is at least one report to the contrary  and it appears likely that complications are under reported .
The unrecognized perforation of the bladder or urethra during the insertion of a mid-urethral sling results in the development of considerable symptoms and impacts negatively on quality of life. The presence of mesh within the bladder may arise either from direct bladder perforation, which is missed at cystoscopy (if done) or from subsequent erosion of a submucosal sling . It is often difficult to distinguish retrospectively between these two events. It has also been suggested that submucosal needle placement with no visible tape at cystoscopy is converted to an occult bladder injury when the trocars are extracted, by trauma from the rough edge of the tape . A thorough cystoscopy is therefore essential to identify subtle submucosal needle positioning. The bladder must be well distended with at least 250 mL of fluid  and some authors recommend the use of a 7° cystoscope .
There is no consensus as to the necessity of cystoscopy at the time of sling insertion. Performing a cystoscopy adds time and expense to this minimally invasive procedure and requires access to a camera stack, light source and cystoscope. In general, cystoscopy is performed after a retropubic approach, but dispensed with for transobturator procedures. However, bladder perforations are encountered with the transobturator route, despite anatomical studies suggesting that this route does not traverse the pelvis so that bladder perforation should be impossible . Authors reporting on cases of missed or eroded intravesical sling material propose that cystoscopy should be anything from ‘considered in selected cases’ to ‘mandatory’ citing the negligible additional morbidity associated with cystoscopy [13,14].
Early experience with third generation mid-urethral slings (TVT-SecurTM, Gynecare, Ethicon, Somerville, NJ, USA) seems to be mixed. The hammock shaped tape is placed in a sub-urethral position without the need for skin incision and a urethral catheter. The early data reported vaginal protrusion of the tape in 12% in the initial 50 patients that reduced to 8% with refinement of the technique in the last 50 . No cases of bladder perforation were reported dispensing with the need for intraoperative cystoscopy. However, more recently bladder perforation was detected intraoperatively in two cases using the TVT-Secur system .
The women that we encountered presented with typical symptoms commencing often early in their postoperative course, although with several months elapsing before diagnosis. Irritative voiding symptoms are often attributed to the not infrequent development of de novo detrusor overactivity after stress urinary incontinence surgery. This occurs in 18.8% of women receiving a retropubic tape, and 11.4% undergoing transobturator tape placement . The 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. In one report, vulval oedema lead to the diagnosis  and another patient unusually was almost asymptomatic and diagnosed incidentally . Bladder stones almost invariably develop if the exposed mesh has been present for >3 months.
Several authors have described their approach to this difficult problem (Table 2) [7,11,18–22] and the approach remains guided by the locally available expertise. For intravesical tape and attendant bladder stone, an open cystotomy may be performed [14,21,23–25]. If mesh is very adherent, then a partial cystectomy may be necessary . An open approach also allowed Peyromaure et al.  to suture bladder mucosa over the exposed cut sling ends, although this does not appear to be necessary for complete healing, which is apparent at follow-up cystoscopy at 1 month. Most authors avoid excising more than the intravesical and at times the intramural tape portions in an effort to preserve continence that is not always successful. After open surgery, patients remain in hospital for 3–6 days with a catheter for much of this time.
Table 2. Management approaches to intravesical or intraurethral mesh
|Reference||Mesh location||Management approach|
|Volkmer et al. ||Intravesical||Open cystotomy and excision of tape and bladder stone|
|Deng et al. ||Intravesical||Partial cystectomy for a long length of embedded tape|
|Irer et al. ||Intravesical||Endoscopic cystolitholapaxy and resection|
|Kielb et al.  and Jorion et al. ||Intravesical||Endoscopic resection assisted by instruments passed via a 5-mm suprapubic laparoscopic port|
|Giri et al. ||Intravesical||Endoscopically using a Holmium laser to cut the tape|
|Deng et al. ||Intraurethral||Excised per vaginum with reconstruction|
|McLennan et al. ||Intraurethral||Cut using hysteroscopic scissors though a cystoscope|
Others have reported the success of a less invasive approach with bladder mesh removed endoscopically , or with the assistance of laparoscopic graspers or scissors passed via a 5-mm suprapubic port to tension the sling during excision [13,20,21,26,27]. However, there are two reports of failed endoscopic removal of cut but adherent tape requiring an open procedure [8,28]. Bladder stones are crushed mechanically or with the lithoclast, while tape is either cut flush with the bladder wall and extracted whole, or resected. Finally, with the potential of using a flexible cystoscope, Giri et al.  used a holmium laser to remove intravesical tape.
Any means whereby intraurethral sling mesh is removed must avoid further worsening of continence. Open excision and reconstruction via a vaginal approach was performed by Deng et al.  and Roumeguère et al.  McLennan  reported an alternative endoscopic approach that avoided the necessity for diathermy using hysteroscopic scissors through a cystoscope. Complications arising from these procedures are described by Deng et al.  in the largest case series to date of 22 women. Of 13 intraurethral perforations repaired, one developed a urethral diverticulum, while of four women with both intraurethral and intravesical tape, three developed a urethral–vaginal fistula that was repaired with a Martius fat pad.
In conclusion, our experience with these nine women shows that in most cases less invasive, endoscopic resection of the exposed tape is sufficient for symptom resolution. Where symptoms persist, complete tape excision is successful. Given the extent of morbidity associated with missed bladder and urethral perforations, cystoscopy should remain a mandatory procedure during any form of mid-urethral sling placement but does not prevent unrecognized perforations in inexperienced hands. A delay to diagnosis is common, despite the early onset of symptoms. The possibility of unrecognized tape perforation or erosion must be considered in patients with LUTS after any form of mid-urethral sling procedure.