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Int Urogynecol J (2006) 17: 422425

DOI 10.1007/s00192-005-0008-3

CASE REPORT

Kenneth Powers . George Lazarou .


Wilma Markus Greston

Delayed urethral erosion after tension-free vaginal tape

Received: 4 May 2005 / Accepted: 7 August 2005 / Published online: 26 April 2006
# International Urogynecology Journal 2006

Abstract Urethral erosions have been reported with various sling materials placed by means of various techniques.
The patient often presents in the immediate postoperative
period, although late presentations have been described.
The diagnosis is made on cystoscopy, and mesh excision
with urethral reconstruction is advocated. We present the
cases of two patients with urethral erosion after midurethral polypropylene sling who presented 3 months after
surgery with urethral pain, mid-urethral blockage and
symptoms of bladder dysfunction. Urethroscopy revealed
the mesh bridging the lumen of the urethra. Trans-vaginal
mesh excision and layered urethral reconstruction was
curative in both patients.
Keywords Urethral erosions . TVT complications .
Urethral injuries

Introduction
Urethral erosions have been described as occurring with all
forms of suburethral sling materials. The typical patient
presents with signs of urethral pain, incomplete bladder
emptying, and associated bladder dysfunction; the diagnosis is made on cystoscopy [1].
Immediate erosions have been reported with proximal
placement of rectus fascia grafts [2] and midurethral placement of monofilament polypropylene mesh [3, 4]. Delayed
erosions have been noted with proximal placement of rectus fascia [5] and GoreTex mesh [6] and after urethral
dilatation for incomplete bladder emptying following midK. Powers (*) . G. Lazarou . W. M. Greston
Division of Female Pelvic Medicine and Reconstructive Surgery,
Department of Obstetrics and Gynecology and Womens Health,
Albert Einstein College of Medicine,
Montefiore Medical Center,
3332 Rochambeau Avenue,
Bronx, NY 10467, USA
e-mail: hoppowers@aol.com
Tel.: +1-718-9206311
Fax: +1-718-9206313

urethral placement of monofilament polypropylene mesh


[7].
We present two cases of delayed urethral erosion after
midurethral polypropylene sling presenting at postoperative month 3 with urethral pain, urgency, frequency, and
midurethral blockage.

Case 1
The patient is a 48-year-old Caucasian female, para 2012
that presented to the urogynecology service complaining of
stress urinary incontinence for the past 3 years associated
with urgency and pelvic pain but with no urinary frequency
or urge incontinence. She reported having tried extendedrelease oxybutynin by her referring physician, with no
improvement in her symptoms. Her prior history was remarkable for bipolar disorder managed with oral administration of Depakote and lithium.
On her initial visit, her body mass index (BMI) was 32.
The straining Q-tip was 90, the catheterized postvoid
residual was 30 cc, and the urethra was markedly tender
without evidence of a periurethral mass. A prolapse exam
revealed all compartments at stage 0. Her urinalysis and
urine culture were negative.
She returned for multichannel, provocative cystometry
and urethral pressure profilemetry. This revealed a bladder
capacity of 300 cc, with pelvic pain on maximal filling and
no evidence of detrusor overactivity. The urethral pressure
profile showed stress urinary incontinence with a normal
urethral closure pressure. Office cystourethroscopy demonstrated no evidence of intraurethral masses, focal intravesical lesions, glomerulations, or mucosal bleeding.
The care options were discussed with the patient. The
patient continued with urgency and pelvic pain after a trial
of oral administration of azithromycin for presumed
bacterial urethritis. She elected for surgical management
of her stress incontinence followed by postoperative medical management of her urgency syndrome. She underwent
placement of tension-free vaginal tape (TVT) as described
by Ulmsten and Petros [8] under general anesthesia, with

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transabdominal bladder compression at a bladder volume


of 300 cc substituting for the cough stress test. A tonsil
clamp was placed between the mesh and posterior urethra,
both to assure adequate spacing was maintained and to
provide adequate countertraction while removing the
sleeves. Intraoperative cystoscopy revealed no intravesical
injury, and the urethra appeared patent and nonconstricted
upon examination in the operating room. She was unable to
void in the recovery room, and she was discharged with a
transurethral catheter and oral administration of antibiotics.
The patient returned to the office 5 days after surgery.
The bladder was filled retrograde through the catheter, and
a trial to void was attempted. She was unable to void, and
the catheter was reinserted. On postoperative week 2, the
Q-tip was 30. She was partially able to void, with a
postvoid residual of 180 cc, and her urine culture was
negative. She was taught clean self-catheterization, which
she was able to perform in the office without complications. She was followed weekly, and at week 3, her home
log showed minimal postvoid volumes, so self-catheterization was discontinued.
The patient returned at postoperative week 14 complaining of recurrent pelvic pain and a new onset of urge
incontinence. Her pelvic exam at that time revealed no
evidence of vaginal mesh erosion, but there was evidence
of significant urethral tenderness. The patient voided spontaneously, but she could not be catheterized due to blockage at the midurethra.
The patient was taken to the operating room, where a
diagnostic urethroscopy was performed under anesthesia,
which demonstrated the TVT mesh bridging the lumen of
the urethra. Cystoscopy revealed no intravesical mesh. A
suburethral incision was performed, with transvaginal
excision and complete removal of the mesh from the
urethral lumen. The urethra was repaired by closing the two
opposing urethrotomy sites with interrupted 3-Vicryl,
closing the vaginal fascia with 2-0 Vicryl using a pants
vest technique, and closing the vaginal mucosa with 2-0
Vicryl.
A transurethral catheter was placed and left in situ for 15
days, at which time, the vaginal exam in the office showed
no evidence of fistula or abscess formation. The patients
bladder was filled retrograde through the catheter. She
subsequently voided to completion, and the catheter was
discontinued. Her vaginal exam 6 weeks later showed an
intact urethra with no evidence of fistula or abscess formation. She complained of urge incontinence and a recurrence of her stress incontinence. She was placed on a 4-mg
daily dose of long-acting tolterodine with bladder retraining and topical estrogen with Kegel exercises. She was
offered a second surgery, but she subsequently went for a
second opinion and was lost to follow-up.

Case 2
The patient is a 35-year-old, para 2012 who presented to
the urogynecology service complaining of urgency, frequency, dyspareunia, pelvic protrusion, and mixed incon-

tinence symptoms, stress greater than urge, that had been


progressing for the past 12 months. Her past medical
history was remarkable for well-controlled hypertension
and bronchitis. Her past surgical history was remarkable
for a prior ovarian cystectomy and a prior abdominoplasty.
On her initial exam, her BMI was 37. The straining Q-tip
was 90, the catheterized postvoid residual was 30 cc, and
the urinalysis and urine culture were negative. The prolapse
exam revealed a stage II central anterior defect and a stage I
posterior defect. The urinary diary revealed a normal 24-h
urine volume with small, frequent voids.
The patient returned for multichannel, provocative cystometry with urethral pressure profilometry. This revealed a
bladder capacity of 345 cc, with no evidence of detrusor
overactivity and no pelvic pain. The urethral cough profile
revealed stress urinary incontinence with a normal urethral
closure pressure. Office cystourethroscopy revealed no
focal lesion, glomerulations, or mucosal bleeding.
The care options were discussed with the patient. She
was started on a 4-mg daily dose of long-acting tolterodine
with bladder retraining using delayed voiding and Kegel
exercises. After 2 months, she reported an improvement of
her urge incontinence, but she reported a persistence of her
stress incontinence and pelvic protrusion. The patient then
elected for surgical treatment for her stress incontinence
and symptomatic pelvic prolapse.
She was taken to the operating room, where an anterior
and posterior colporrhaphy were performed under general
anesthesia, in conjunction with placement of a TVT under
general anesthesia using the technique described in case 1.
Intraoperative cystoscopy revealed no intravesical mesh or
urethral compromise, and the urethra appeared patent and
nonconstricted. The patient was unable to void in the
recovery room, so the transurethral Foley was replaced,
and the patient was discharged on an oral administration of
antibiotics.
The patient returned to the office 5 days after surgery.
Her bladder was filled retrograde, but she was not able to
void completely, so the Foley was replaced. She returned at
postoperative week 2. Her Q-tip was 50, the urethra was
nontender, and her postvoid residual was 200 cc. She was
taught self-catheterization, which she was able to perform
in the office without complication. Her urine culture was
positive, and she was treated with antibiotics sensitive to
the identified organism; the posttreatment culture was negative. She was followed weekly, and at week 5, her home
log showed minimal postvoid volumes, so self-catheterization was discontinued.
She presented at postoperative week 15 complaining of a
new onset of urgency, frequency, and dyspareunia. A pelvic exam at that visit revealed no evidence of vaginal mesh
erosion, but there was evidence of significant urethral pain.
The patient voided spontaneously, but she could not be
catheterized due to midurethral blockage; the urine culture
was negative. The prolapse exam revealed all compartments at stage 0.
She was taken to the operating room, where diagnostic
urethroscopy under anesthesia revealed the TVT mesh
bridging the lumen of the urethra, as illustrated in Fig. 1.

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Cystoscopy revealed no intravesical mesh. A suburethral


incision was performed, with transvaginal excision and
complete removal of the mesh from the urethral lumen. The
urethra was repaired by closing the two opposing urethrotomy sites with interrupted 3-0 Vicryl, closing the vaginal
fascia with 2-0 Vicryl using a pantsvest technique, and
closing the vaginal mucosa with 2-0 Vicryl.
A transurethral catheter was placed and left in situ for 15
days, at which time, the vaginal exam in the office showed
no evidence of fistula or abscess formation. The patients
bladder was filled retrograde through the catheter. She
subsequently voided to completion, and the catheter was
discontinued. The patient complained of mixed incontinence at this visit. She was placed on intravaginal estrogen
cream twice weekly and a 10-mg daily dose of extendedrelease oxybutynin with bladder retraining. Her urine culture was negative. She returned at week 6 reporting an
improvement of her urge incontinence, but she reported a
recurrence of her stress incontinence. A pelvic exam revealed an intact urethra with no evidence of fistula or
abscess formation. She was offered a second surgery, but
she subsequently went for a second opinion and was lost to
follow-up.

Discussion
Urethral erosions after suburethral slings have been noted
with a wide variety of graft materials. Most urethral
erosions are suspected due to the presenting complaints of
urethral pain, incomplete voiding, and (bladder-dysfunction-deleted) irritative voiding symptoms; cystourethroscopy is required to make the diagnosis [1].
One case report described an urethral erosion in the
immediate postoperative period after placement of an
autologous rectus fascia graft at the proximal urethrovesical junction, requiring transvaginal graft removal and
urethral reconstruction [2]. Immediate erosions have been

similarly noted with a midurethral placement of monofilament polypropylene mesh, again treated with transvaginal
graft removal and urethral reconstruction [3, 4]. Delayed
erosions have been reported with a variety of graft materials. Handa and Stone described urethral erosion 2 months
after proximal placement of a rectus fascia sling [5]. Bezerra
and Bruschini similarly reported delayed urethral erosion
diagnosed after placement of a proximal GoreTex sling [6].
Vassallo et al. described erosion diagnosed after serial urethral
dilatations done for prolonged urinary retention secondary to
midurethral placement of monofilament polypropylene mesh
[7].
Although some authors advocate transurethral resection
of the mesh in the management of urethral erosion [9], the
majority of experts favor transvaginal removal of the mesh
followed by layered urethral reconstruction [1012]. In our
cases, mesh excision and repair of the urethrotomy sites
resulted in the successful healing of the urethral erosion.
These cases represent our only instances of intraluminal
urethral erosions after TVT. It is unclear to the authors if
they represent a tissue necrosis injury from inadvertent
overadjustment or twisting of the sling at the time of the
original surgery, a consequence of traumatizing the urethra
with repetitive catheterizations, or mesh migration after the
initial recovery period. However, given our concerns that
use of the Cred maneuver may generate abdominal pressure in excess of that from a patient-generated cough
stress test (CST), leading to maladjustment, excess sling
tension, and subsequent urethral injury, we have modified
our technique for TVT adjustment under general anesthesia. We now maintain a space under the urethra with a
Kelly or tonsil clamp without using the Cred maneuver.
With this approach, we have had no further complications
as described.
These cases are presented to alert the clinician to the
possibility that urethral erosions after a midurethral sling
can present several months after the initial surgery. The
authors advocate complete transvaginal mesh removal
from the urethra, and carefully layered urethral reconstruction, as potentially curative in cases of midurethra sling
erosions into the urethral lumen.

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Fig. 1 Diagnostic urethroscopy under anesthesia revealed the TVT


mesh bridging the lumen of the urethra

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