FEMALE UROLOGY

Perioperative complications: the first 140 polypropylene pubovaginal slings
Kobashi KC, Govier FE
The Continence Center at Virginia Mason, 1100 Ninth Avenue, Seattle, Washington 98101, USA
J Urol. 2003; 170: 1918-21

• Purpose: Two widely used tensionless mid urethral slings currently available are the SPARC polypropylene sling (American Medical Systems, Minneapolis, Minnesota) and the TVT (tensionless vaginal tape, Ethicon, New Brunswick, New Jersey). As with the TVT system, the SPARC has been suggested as an outpatient procedure. We present the early complications of our first 140 slings, based on which we recommend that observation of all patients overnight following the SPARC sling be considered.
• Materials and Methods: We retrospectively reviewed the charts of the first 140 patients who received the SPARC polypropylene pubovaginal sling at our institution to evaluate for early complications requiring intervention. Because we wished to evaluate for occult bleeding, we checked the hematocrit on postoperative day 1 in the last 57 patients regardless of blood loss in the operating room.
• Results: A total of 6 patients required intervention in the early postoperative period, including transfusion in 4 immediately postoperatively for retropubic bleeding. One patient had presented with pelvic pain and vaginal bleeding 1 week postoperatively and was found to have a large retropubic hematoma that required percutaneous drainage. The final patient was discharged home on postoperative day 1 in stable condition but presented on postoperative day 4 with drainage from a suprapubic incision. She had a perforation through a loop of small bowel that required resection of a short segment of the bowel and removal of the sling. The mean decrease in hematocrit from preoperative to postoperative day 1 was 7.1% (range 1% to 14%) despite a mean intraoperative blood loss in this group of 170 cc (range less than 50 to 700 cc).
• Conclusions: We recommend caution with any patient who receives a sling that requires passage of needles through the retropubic space, which can result in occult retropubic bleeding, and dilation of the tract. While visceral injury is exceedingly rare, it must be discussed as a possible risk of the surgery. We continue to advocate SPARC as an excellent sling option but we caution surgeons of the potential complications and urge careful postoperative monitoring. We recommend that SPARC not routinely be considered as an outpatient procedure.
  
  
• Editorial Comment
  The authors retrospectively reviewed the charts of 140 patients who underwent a polypropylene suburethral pubovaginal sling using the SPARC device. The patients’ charts were examined and notations were made regarding the rate of post-operative hemorrhage with or without transfusion as well as bowel injury. Based on the review the authors recommend overnight observation after this surgery secondary to potential complications and discourage its performance as an outpatient procedure.
  This is another article from two outstanding urologists describing their experience with the SPARC procedure and potential complications of same (1). I feel the paper is excellent and warrants close reading by the interested urologic surgeon. The only shortcoming of the paper I could detect was that though the title claims this paper to be peri-operative complications, the descriptions were fairly limited to that of bleeding and potentially catastrophic bowel injury. Because of the wealth of their experience, the authors have the potential to describe all the complications associated with this specific procedure including dyspareunia, tape erosions, urinary retention, persistent incontinence, as well as anesthetic complications of pneumonia, throat/tracheal irritation etc.
  The authors do describe the SPARC being potentially different from the TVT operation secondary to the SPARC system using a “finger guided delivery of the smaller needles from top to bottom”. This is somewhat different from some of the previous descriptions of the operation, which describe a shifting type maneuver of the needle once it perforates the rectus fascia with the needle, then exiting the anterior vaginal epithelium as opposed to a complete finger guided delivery that is done with a formal opening of the urethral pelvic ligament. It may have been of interest to hear the authors’ thoughts on whether the bowel injury could have been avoided if the urethral pelvic ligament had been opened and adhesion swept off the back of the pubic bone prior to the passage of the suture ligature carriers. Nevertheless, the authors should be commended in that the paper is excellent for its emphasis to the urologic surgeon that just because one may do an operation as an outpatient, it may not necessarily be the safest route of therapy and that in this specific type of operation overnight stay may be warranted secondary to potential post-operative hemorrhage or bowel injury.

Reference
1. Petrou SP: Editorial Comment. Management of vaginal erosion of polypropylene mesh slings. Int Braz J Urol. 2003, 29: 280-1.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA