FEMALE UROLOGY

Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh
Domingo S, Alama P, Ruiz N, Perales A, Pellicer A
Department of Obstetrics and Gynaecology, Hospital Universitario Dr. Peset, Valencia, Spain
J Urol. 2005; 173: 1627-30

• Purpose: We studied the diagnosis, management and prognosis of vaginal mesh erosion using a thermally bonded nonwoven polypropylene mesh in a transobturator suburethral tape procedure for the surgical treatment of stress urinary incontinence in women.
• Materials and Methods: A total of 65 patients diagnosed with stress urinary incontinence underwent a transobturator suburethral tape procedure with a fusion welded, nonwoven, nonknitted polypropylene mesh, with or without a central silicone coated section, at our institution. All women were followed and if vaginal erosion was diagnosed, cystoscopy and vaginoscopy were performed, the mesh was partially or completely removed and, if necessary, posterior cough test and urodynamic study were performed.
• Results: Of the 65 patients 9 (13.8%) were diagnosed with vaginal erosion at the vaginal incision during a relatively long postoperative period (mean 290 days). All presented with vaginal discharge and 1 had a severe complication (obturator abscess). Complete mesh removal was necessary in 8 patients and only 2 (22%) had recurrent stress urinary incontinence.
• Conclusions: A 13.8% rate of vaginal mesh erosion using a nonwoven thermally bonded polypropylene mesh was reported. This complication was probably due to the characteristics of the mesh and not to the transobturator approach. Complete removal of the tape is recommended and the continence status prognosis is good (78%).
  
  
• Editorial Comment
  The authors review their experience with vaginal erosion in a group of patients that underwent the transobturator suburethral tape procedure. They report a 13.8% rate of vaginal erosion. They note that all patients presented with a vaginal discharge (some being quite impressively copious) and one patient had a severe complication of an obturator abscess. The vast majority of the patients underwent complete mesh removal with subsequent continence level remaining at 78%. The authors felt the complication was not secondary to the actual transobturator technique but merely representative of characteristics of the mesh utilized.
  The authors should be complimented on their report on vaginal erosions after transobturator tape procedures. This procedure, as developed by Delorme, is achieving new levels of popularity and thus any review or edification regarding this new technique is of extreme value. Key points include the presentation of persistent vaginal discharge in all of the patients with vaginal erosion, symptoms of potential dyspareunia and fever presenting in a metachronous fashion. It would have interest to note if the authors treated any of the vaginal erosions in the same conservative manner as delineated by Kobashi & Govier (1). The effect of the material utilized as the sling as opposed to the actual technique has been commented on in previous reports. With regards to the actual tension-free vaginal tape procedure and the findings of erosions, it was noted that using a tape of polytetrafluoroethylene or polyethylene terephthalate, Ulmsten & Petros reported a 10% rate of erosion (2). When TVT has been performed utilizing different materials, the erosion rate was markedly diminished (3). It is with great probability that the same phenomenon regarding diminishing erosion rates and the transobturator technique will be noted in view of the evolution to new tapes such as ArisÔ that is knitted and has a larger pore size of 550 x 170 microns. Lastly, though the sling removal was completed it did not seem to affect the continence status (78%). This rate mirrors other reports of continence levels after sling excision or urethrolysis including those performed after using a retropubic technique and is quite thought provoking in view that the TOT does not really affect a retropubic fibrosis (4).

References
1. Kobashi KC, Govier FE: Management of vaginal erosion of polypropylene mesh slings. J Urol. 2003; 169: 2242-3.
2. Ulmsten U, Petros P: Intravaginal slingplasy (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scan J Urol Nephrol. 1995; 29: 75-82.
3. Klutke JJ, Klutke CG: The tension-free vaginal tape procedure: innovative surgery for incontinence. Curr Opin Obstet Gynecol. 2001; 13: 529-32.
4. Petrou SP, Young PR: Rate of recurrent stress urinary incontinence after retropubic urethrolysis. J Urol. 2002; 167: 613-15.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida, USA