Professional Documents
Culture Documents
DOI 10.1007/s00192-005-0008-3
CASE REPORT
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
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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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-
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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.
References
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7. Vassallo BJ, Kleeman SD, Segal J, Karram MM (2003)
Urethral erosion of a tension-free vaginal tape. Obstet Gynecol
101:10551058
8. Ulmsten U, Petros P (1995) Intravaginal slingplasty (IVS): an
ambulatory surgical procedure for treatment of female urinary
incontinence. Scand J Urol Nephrol 29:7582
9. McLennan MT (2004) Transurethral resection of transvaginal
tape. Int Urogynecol J Pelvic Floor Dysfunc 15:360362