|
NEUROUROLOGY
& FEMALE UROLOGY
Voiding
Dysfunction Following Removal of Eroded Synthetic Mid Urethral Slings
Starkman JS, Wolter C, Gomelsky A, Scarpero HM, Dmochowski RR
Department of Urologic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
J Urol. 2006; 176: 1040-4
- Purpose:
Voiding dysfunction following genitourinary erosion of synthetic mid
urethral slings is not clearly reported. We investigated the incidence
of voiding dysfunction in patients following sling excision due to vaginal,
urethral or intravesical mesh erosion.
- Materials
and Methods: Retrospective review identified 19 patients with
genitourinary erosion of polypropylene mesh slings. Comprehensive urological
evaluation was performed in all patients, and perioperative and postoperative
data were analyzed. Voiding dysfunction was defined as refractory storage
symptoms, emptying symptoms and pelvic pain. All subsequent medical
and surgical interventions were recorded.
-
Results:
In 19 patients a total of 11 vaginal, 7 intravesical and 5 urethral
erosions occurred. Mean patient age was 52 years (range 32 to 69) and
average followup was 8.4 months (range 3 to 34). Average time from symptom
onset to sling removal was 10.1 months (range 1.5 to 38). Of the 19
patients 14 (74%) presented with multiple symptoms. Symptoms varied,
including refractory pain, recurrent infections and bladder storage/emptying
dysfunction. Urodynamic studies were abnormal preoperatively and postoperatively
in 9 of 13 (69%) and 4 of 6 patients (67%), respectively. Following
surgery lower urinary tract symptoms resolved completely in only 4 of
the 19 patients (21%). Stress incontinence recurred in 8 of the 19 patients
(42%). Five patients underwent simultaneous pubovaginal sling, of whom
none had recurrent stress urinary incontinence. Only 9 patients (47%)
considered themselves dry with no pads following surgery. Four patients
required further surgery for refractory voiding symptoms.
- Conclusions:
Voiding dysfunction is not an uncommon finding after sling excision
in the setting of genitourinary erosion. It may cause additional patient
morbidity.
- Editorial
Comment
The authors give a sobering report on their experience with voiding
dysfunction after erosion of synthetic mid-urethral slings. Their study
included vaginal, vesical, and urethral erosions. The patient population
was relatively young (average age 52) with average follow-up after intervention
being less than 1 year. This report of persistent voiding dysfunction
following removal of the eroded material as well as the high rate of
incontinence after reparative surgery can be deflating to a treating
physician. The incidence of recurrent incontinence is somewhat higher
than that reported for transobturator suburethral tape erosion and subsequent
explantation (1). The authors point out that in their experience, preoperative
urodynamics prior to the removal of the erosion may be of marked value.
In addition, it is noted that the presentations of tape erosion may
be quite variable necessitating a high index of suspicion and a careful
evaluation for appropriate diagnosis. One may heed the authors’
advice that aggressive mesh removal for vaginal extrusion is not needed
in all situations and that surgical judgment should be exercised. They
also do debate the need for synchronous placement of pubovaginal sling
at the time of mesh removal to prevent recurrent stress urinary incontinence.
Reference
1. Domingo S, Alama P, Ruiz N, Perales A, Pellicer A: Diagnosis, management
and prognosis of vaginal erosion after transobturator suburethral tape
procedure using a nonwoven thermally bonded polypropylene mesh. J Urol.
2005; 173: 1627-30.
Dr.
Steven P. Petrou
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA |