Laparoscopic Surgical Complete Sling Resection for Tension-Free Vaginal Tape–Related Complications Refractory to First-Line Conservative Management: A Single-Centre Experience

doi:10.1016/j.eururo.2010.04.025

European Urology

Volume 58, Issue 2, August 2010, Pages 270-274

https://doi.org/10.1016/j.eururo.2010.04.025 Get rights and content

Abstract

Background

Tension-free vaginal tape (TVT) has been largely used for the management of stress urinary incontinence. In certain cases, however, this procedure results in bothersome complications that lead to a complete resection.

Objective

We assessed the technical feasibility and functional outcome after complete laparoscopic resection of TVT.

Design, setting, and participants

Thirty-eight women with TVT-related complications refractory to first-line management underwent a complete laparoscopic tape resection between 2001 and 2009.

Surgical procedure

Complete laparoscopic resection was achieved with either an intra- or extraperitoneal laparoscopic approach. Laparoscopy was performed with four ports: a 10-mm umbilical telescope port, two 5-mm ports placed medially to the anterior superior iliac spines, and a 10-mm port placed at the midpoint between the pubis and umbilicus. The two half-tapes were dissected towards the urethra and removed.

Measurements

All data referring to patient demographics, surgery, tape-related complication, and perioperative outcomes were recorded.

Results and limitations

The mean age of the patients was 66.2 yr (range: 45–79 yr). TVT-related complications included bladder erosion, vaginal extrusion, and bladder outlet obstruction or groin pain. The resection took place at a mean time of 25 mo (range: 6–80 mo) after TVT placement. Resection was complete in all patients, within a mean operative time of 110 min (range: 50–240 min). All women reported a total decrease of symptom-related complications within a mean follow-up period of 37.9 mo (range: 2–80 mo). However, recurrent incontinence occurred in 65.7% (n = 25) of the patients. The main limitation of the study was the lack of a validated questionnaire to assess the evolution of functional disorders.

Conclusions

Complete laparoscopic resection of TVT is safe and technically feasible. In the limited number of women who have persisting disabling symptoms after conservative management, urologists must be aware that a complete resection can help resolve the symptoms.

Introduction

Midurethral sling (MUS) procedures are now considered the gold standard for surgical management of female stress urinary incontinence (SUI). Owing to its technical feasibility and long-term success rate, tension-free vaginal tape (TVT) was the first procedure to revolutionise and challenge the management of SUI [1], [2], [3]. TVT was extensively performed until the emergence of the transobturator approach and the third generation of TVT (TVT-SECUR, Ethicon, Somerville, NJ, USA), which led to a decrease in TVT use by urologists and gynaecologists [4], [5], [6], [7].

Thus, >1 million TVT slings have been placed worldwide since its first description in 1996 [8]. TVT has always been considered to be a safe and minimally invasive anti-incontinence procedure [9]. However, a growing number of postoperative complications and unexpected surgical injuries associated with the retropubic route have been reported in recent literature [10], [11], [12]. These complications include perioperative and postoperative complications such as bladder injury, mesh erosion, chronic pain, or infection.

Among these complications, some are refractory to first-line conservative management and require a more radical surgical treatment. Indeed, surgical teams have already reported their management of MUS complications, but these experiences are still scarce in the current literature [13], [14]. To date, only two studies have demonstrated that resection of a MUS is safe and technically feasible using a laparoscopic approach and that it helps to manage tape-related complications in specific cases [12], [15]. In the current study, we report our specific clinical experience of TVT-related complications that required complete laparoscopic resection.

Section snippets

Population

All women who were sent to our academic urology department for TVT-related complications between January 2001 and December 2009 were retrospectively considered for inclusion in the study. The following data were extracted from their charts: age, body mass index (BMI), initial type of incontinence, past medical history of previous pelvic support and anti-incontinence procedures, date of the suburethral tape resection procedure, complications, length of bladder catheterisation and of hospital

Results

Overall, 38 women with a mean age of 66.2 ± 10 yr (range: 45–79 yr) at the time of resection were included in the analysis. The median BMI was 25.5 kg/m² (range: 22–32 kg/m²). All TVTs had been implanted at another centre, and the patients were referred to our centre for management of tape-related complications.

Discussion

Over the last two decades, TVT surgery had become the most common treatment for female SUI until the emergence of the transobturator tape and third-generation TVT [17]. Most teams that manage urinary incontinence in female patients have communicated data on the best treatment options, but very few have reported the complications of these treatments. However, widespread use of the retropubic route has resulted in an increasing number of reported complications, ranging from 4.3% to 75.1% in a

Conclusions

TVT is still considered the primary surgical choice for female SUI. Although TVT offers an effective SUI treatment, it has significant associations with postoperative complications, leading (in specific cases) to a radical surgical management after the failure of first-line treatment. Complete laparoscopic resection of TVT is safe and technically feasible and can help resolve bothersome symptoms. However, women should be warned of the risk of recurrent incontinence.

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Cited by (38)

Surgical complications in adult urology: Pelvic and perineal surgery
2022, Progres en Urologie
Les chirurgies pelvipérinéales et, notamment, celles de l’incontinence urinaire à l’effort et du prolapsus sont des chirurgies fonctionnelles, qui nécessitent une sélection rigoureuse des patients et une évaluation de la gêne pour espérer des résultats chirurgicaux satisfaisants et réduire les taux d’échec et de complications. Avant de proposer une chirurgie pelvipérinéale, le risque de complications potentielles doit être soigneusement évalué et abordé avec les patients. L’attention récente, portée aux complications potentielles de l’implantation de treillis de renfort périnéal, a sensibilisé la communauté urologique au signalement des complications. Ce chapitre se concentrera sur les complications des chirurgies de l’incontinence urinaire d’effort et, en particulier, des bandelettes sous urétrales synthétiques rétropubiennes ou transobturatrices. On évoquera également les complications des colposuspensions, des frondes pubovaginales, des sphincters urinaires artificiels, des ballonnets ajustables péri-urétraux et des injections péri-urétrales d’agents comblants) et de la promontofixation. Il sera abordé l’épidémiologie des complications, le bilan minimal à réaliser, le traitement et la prévention.
Pelvic and perineal surgeries and in particular those for stress urinary incontinence and prolapse are functional surgeries, which require careful selection of patients and assessment of discomfort to expect satisfactory surgical results and reduce failure rates and of complications. Before offering pelvic and perineal surgery, the risk of potential complications should be carefully assessed and discussed with patients. Recent attention to the potential complications prosthetic mesh has raised awareness in the urological community to report complications. This chapter will focus on the complications of surgeries used for stress urinary incontinence (synthetic retropubic or transobturator suburethral slings, colposuspension, pubovaginal slings, artificial urinary sphincter, adjustable periurethral balloons and periurethral injections of bulking agents) and sacrocolpopexies. The epidemiology of complications, the minimum assessment to be carried out, treatment and prevention will be discussed.
Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings
2022, Urology
Citation Excerpt :
Here we report a large case series of painful synthetic slings focusing on the treatment outcomes of partial and complete sling removal with regard to pain resolution, postoperative urinary incontinence, and the need for additional reconstructive procedures. In our series, 78.1% of patients experienced pain resolution or improvement after sling removal, consistent with other studies.10-13 However, few prior studies have categorized sling removal into complete vs partial removal, and few have categorized pain into resolution vs improvement.
To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal.
We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009–2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed.
87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P = 0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P = 0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%).
Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.
Managing pain after synthetic mesh implants in pelvic surgery
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
In these patient’s excision of the mesh may not alter the clinical course as the response appears to be more systemic. This is an area where further research is urgently needed to guide appropriate management of these women as there is a lack of evidence or data relating to this group, although there are small case series suggesting solutions [21]. Data on the outcome of surgery to remove the mesh/tape is beginning to emerge [22,23], but at present patients should be warned that surgery may not resolve their symptoms.
Pelvic mesh surgery has courted controversy with around 10% of patients experiencing complications. This article concentrates on the factors around pain, its presentation and management. Immediate pain is related to insertion and immediate removal recommended. With later presentation excision of the mesh relieves pain in up to 80% of women. Infection may be contributory but in refractory cases other factors maybe involved. Idiosyncratic reaction to mesh without risk factors appears to be relatively rare.
Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder
2018, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
In our series, laparoscopy was only used twice (successfully) to treat complications arising from the cystoscopy approach. The laparoscopy approach for bladder-penetrating MUSs has been widely described for excision of bladder sling exposure after a retro-pubic MUS [43,56]. Roslan and Markuszewski [32] published an interesting series in 2013, using an exclusive trans-vesical suprapubic approach with a single trocar and insufflation of the bladder with carbon dioxide.
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.
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.
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.
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.
Placement of tension-free vaginal tape in women with stress urinary incontinence: Long-term functional outcomes in a prospective series
2017, Progres en Urologie
Évaluer les résultats fonctionnels à long terme de la bandelette sous-urétrale rétropubienne TVT pour le traitement de l’incontinence urinaire d’effort (IUE) féminine.
Une étude monocentrique prospective a inclus les femmes ayant une IUE par hypermobilité urétrale traitées par une bandelette rétropubienne TVT par le même chirurgien entre septembre 1998 et septembre 2000. Les patientes ont été évaluées à 1, 3, 6 et 12 mois après la chirurgie, puis annuellement. Les données suivantes ont été recueillies : calendrier mictionnel, résidu post-mictionnel, test d’incontinence urinaire d’une heure, questionnaire de sévérité des symptômes urinaires, score de qualité de vie, complications postopératoires. Les taux de continence objective (absence de fuite urinaire à l’effort lors de l’examen clinique) et subjective (absence de fuite urinaire, quel que soit le type, rapportée par la patiente) ont été rapportés.
Cinquante-huit patientes d’âge médian 59 ans (IQR 49–67 ; min 21–max 78) ont été incluses. Au terme du suivi médian de 10,2 ans (IQR 1,4–16,0 ; min 1–max 13,2), les taux de continence urinaire objective et subjective ont été respectivement de 93 % et 78 % et sont restés stables dans le long terme. Le test d’incontinence urinaire d’une heure, les scores du questionnaire de sévérité des symptômes urinaires et de qualité de vie ont été significativement améliorés. L’utilisation d’autosondages intermittents a été nécessaire chez 3 femmes en postopératoire. Une section de bandelette et l’ablation d’une autre bandelette ont été réalisées chez 2 femmes ayant des douleurs pelviennes chroniques. Une patiente a rapporté des infections urinaires récidivantes. Un taux d’urgenturie de novo de 10 % a été rapporté.
Les résultats fonctionnels après la mise en place d’une bandelette rétropubienne TVT sont satisfaisants et stables sur le long terme. Cette procédure améliore la qualité de vie avec une morbidité faible.
3.
To evaluate the long-term functional outcomes after retropubic tension-free vaginal tape (TVT) placement to treat female stress urinary incontinence (SUI).
From September 1998 to September 2000, we prospectively enrolled all consecutive women in our center suffering SUI caused by urethral hypermobility. All women had a retropubic TVT inserted by the same surgeon. Patients were evaluated at 1, 3, 6 and 12 months postoperatively, and annually thereafter. Postoperative assessment included a measurement of post-voiding residual volume, urinalysis, a 1-hour pad test, a urinary symptom questionnaire, and an assessment of quality-of-life. Objective continence (defined as no urine leakage at clinical examination) and subjective continence (defined as no urine leakage, whatever the mechanism, reported by the patient) were reported.
Overall, 58 consecutive women (median age 59; IQR 49–67; min 21–max 78) were evaluated. Median follow-up was 10.2 years (IQR 1.4–16.0; min 1–max 13.2). At the last follow-up, objective and subjective continence rates were 93% and 78%, respectively and remained stable in the long run. Pad tests, urinary symptom questionnaire scores and quality-of-life were significantly improved. Self-intermittent catheterisation was required by three women. A section of one TVT and removal of another tape was undertaken in two women with chronic pelvic pain. One patient had a chronic urinary infection. Rate of de novo urgency was 10%.
TVT implantation offered good and stable functional long-term outcomes. This procedure enhanced quality-of-life and had low morbidity.
3.
How to Deal with Pain Following a Vaginal Mesh Insertion
2016, European Urology Focus

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¹: The first two authors contributed equally to this paper.

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Surgery in MotionLaparoscopic Surgical Complete Sling Resection for Tension-Free Vaginal Tape–Related Complications Refractory to First-Line Conservative Management: A Single-Centre Experience

Abstract

Background

Objective

Design, setting, and participants

Surgical procedure

Measurements

Results and limitations

Conclusions

Introduction

Section snippets

Population

Results

Discussion

Conclusions

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

J Urol

J Urol

J Urol

J Urol

Pain

Eur Urol

Eur Urol

Urology

Surgery in Motion
Laparoscopic Surgical Complete Sling Resection for Tension-Free Vaginal Tape–Related Complications Refractory to First-Line Conservative Management: A Single-Centre Experience