PDF-525.pdf 436 | Keywords: stress urinary incontinence, complications, prosthesis implantation, surgery, female INTRODUCTION Urethral erosion is an uncommon, but serious complication following syn-discuss a woman who presented with urethral erosion, vaginal erosion, - ment. She was managed by sling excision with simultaneous rectus fascia sling surgery. Most such patients have been managed by urethral reconstruction and subsequent staged incontinence surgery, for fear of urethral complications. We - thral erosion was carried out along with an autologous rectus fascia sling.(1,2) CASE REPORT - where. Details of the type of the tape used and operative notes were not available. The patient mentioned that a transobturator polypropylene mesh had been placed using a mesh kit. Early in the postoperative period, she had storage symptoms that initially responded to empirical 4 mg long-acting tolterodine. She presented 4 months postoperatively - nal erosion and nodular induration at the groin exit wounds. Urodynamic study 2 Sanjay Sinha, Rooma Sinha, Jyotsna B Reddy, Srinivas R Sirigiri, Srinivas K Kanakamedala Urethral Erosion With Recurrent Stress Incontinence Following Transobturator Tape Surgery Urethral Repair With Simultaneous Pubovaginal Sling Corresponding Author: Sanjay Sinha, MCh Department of Urol- ogy, Apollo Hospital, Hyderabad, India Tel: +91 406 673 7937 Fax: +91 402 320 1015 E-mail: drsanjaysinha@ hotmail.com Received January 2010 Accepted September 2010 Departments of Urology and Gynecology, Medwin Hospital, Hyderabad, India Case Report Case Report 437Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L distal to the bladder neck (Figure 1). Urine culture Magnetic resonance imaging did not show any ab- The patient underwent excision of the suburethral tape, 2-layered reconstruction of the urethra using - tius labial fat pad interposition, and simultaneous - rity was checked by methylene blue. Labial fat was interposed between sling and the urethra. The suprapubic and urethral catheters were re- moved after 3 weeks. At 27 months follow-up, she had no subjective incontinence, urgency, or pain. - show any leak. She had negligible residual on ul- trasonographic evaluation. DISCUSSION Since the initial descriptions of the tension-free these procedures have become the most commonly (3,4) Urethral erosion (5) sign of a technical error.(6) Erosion occurs follow- ing slings that are too tight or too close to the ure- thra and presentation may be delayed up to 2 years. Type of sling material (biological or synthetic, ma- croporous polypropylene or otherwise) and quality Erosion may present with urethral discomfort, urinary incontinence. Diagnosis requires a high index of suspicion, and cystoscopy is important in patients with intractable symptoms. Patients with urethral erosion or recur- rent incontinence should undergo detailed evalua- tion, including urodynamic study and ultrasonog- raphy. Simple out-patient transvaginal introital ultrasonography may provide valuable clues to the presence of an erosion.(5,7) - ed sepsis, magnetic resonance imaging can help in (8) This may dictate the need for more extensive tape removal. Magnetic resonance imaging, however, is not suit- contrast to delayed secondary urethral erosion, primary intra-operative urethral injury should be Tape procedure may proceed only if the injury is deemed minor. There is no consensus regarding the optimal man- agement of these patients. A range of reconstruc- tive surgeries have been described, including en- doscopic tape removal alone and vaginal removal with urethral reconstruction with or without inter- position of vascularized autologous tissue. Mild - ter transurethral tape excision.(9) Of 34 patients in a - agement of sling erosion.(5) However, only three patients have so far been reported to have under- gone simultaneous autologous pubovaginal sling placement at the time of erosion management.(1,2) not warranted and removal of the sub-urethral por- Figure 1. Cystoscopic image of erosion in the floor of the urethra showing the tape mesh. There was an extensive erosion encom- passing more than one quadrant of the urethral lumen. Pubovaginal Sling Erosion | Sinha et al 438 | tape excision was performed in view of severe painful groin indurations along with the erosion. The duration of postoperative catheter placement is not standardized and the surgeon must use dis- cretion based on the severity of the problem and or coated tapes, in view of the risk for progressive erosions, strong consideration must be given for total tape excision. Stress urinary incontinence does not always recur after tape excision; hence, prophylactic re-do in- continence surgery is unwarranted.(5,11,12) However, - entation, careful consideration must be given to the simultaneous placement of a pubovaginal sling at the time of erosion repair. This is technically fea- to explore the doubly-scarred periurethral area in - pose healthy vascularized tissue, such as a Martius such women. Synthetic tapes may carry higher risk of erosion and should be used with caution. Poor quality of vaginal and periurethral tissues may anyway dictate the need for staged reconstruction. reconstruction, a standard autologous pubovaginal sling can be performed.(13) - tients, synthetic sling may be placed as an interval procedure. CONFLICT OF INTEREST None declared. REFERENCES 1. Starkman JS, Wolter C, Gomelsky A, Scarpero HM, Dmo- chowski RR. Voiding dysfunction following removal of erod- ed synthetic mid urethral slings. J Urol. 2006;176:1040-4. 2. Powers K, Lazarou G, Greston WM. Delayed urethral erosion after tension-free vaginal tape. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:422-5. 3. Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulato- ry surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7:81-5; discussion 5-6. 4. Delorme E. [Transobturator urethral suspension: mini-in- vasive procedure in the treatment of stress urinary inconti- nence in women]. Prog Urol. 2001;11:1306-13. 5. Velemir L, Amblard J, Jacquetin B, Fatton B. Urethral erosion after suburethral synthetic slings: risk factors, diagnosis, and functional outcome after surgical management. Int Urogy- necol J Pelvic Floor Dysfunct. 2008;19:999-1006. 6. Boublil V, Ciofu C, Traxer O, Sebe P, Haab F. Complications of urethral sling procedures. Curr Opin Obstet Gynecol. 2002;14:515-20. 7. Tunn R, Gauruder-Burmester A, Kolle D. Ultrasound diagno- sis of intra-urethral tension-free vaginal tape (TVT) position as a cause of postoperative voiding dysfunction and retro- pubic pain. Ultrasound Obstet Gynecol. 2004;23:298-301. 8. Zumbe J, Porres D, Degiorgis PL, Wyler S. Obturator and thigh abscess after transobturator tape implantation for stress urinary incontinence. Urol Int. 2008;81:483-5. 9. Wai CY, Atnip SD, Williams KN, Schaffer JI. Urethral erosion of tension-free vaginal tape presenting as recurrent stress uri- nary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:353-5. 10. Mesens T, Aich A, Bhal PS. Late erosions of mid-urethral tapes for stress urinary incontinence--need for long-term follow- up? Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:1113-4. 11. Madjar S, Tchetgen MB, Van Antwerp A, Abdelmalak J, Rack- ley RR. Urethral erosion of tension-free vaginal tape. Urol- ogy. 2002;59:601. 12. Haferkamp A, Steiner G, Muller SC, Schumacher S. Urethral erosion of tension-free vaginal tape. J Urol. 2002;167:250. 13. Vassallo BJ, Kleeman SD, Segal J, Karram MM. Urethral erosion of a tension-free vaginal tape. Obstet Gynecol. 2003;101:1055-8. Figure 2. A total of 8 cm of tape was excised leaving behind small segments passing through the obturator foramen. Tape microbi- ology showed candidal growth. Details of the type of tape used were not available. Case Report