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NEUROLOGY
& FEMALE UROLOGY
Complications
of mid urethral slings: important outcomes for future clinical trials
Daneshgari F, Kong W, Swartz M
Department of Urology and Female Pelvic Surgery, Upstate Medical University,
Syracuse, New York, USA
J Urol. 2008; 180: 1890-7
- Purpose:
Mid urethral slings are becoming the first line surgical treatment for
stress urinary incontinence in women. We reviewed the complications
of mid urethral sling placement and their potential pathophysiology.
Materials and Methods: We conducted a literature search on MEDLINE from
1995 to 2007 using the key words sling, complications, mid-urethral
slings, transvaginal tape, transobturator tape, trials, pathophysiology
and complications. The Cochrane database was also searched. The results
were summarized according to the type of mid urethral slings reported.
Results: There were 928 MEDLINE citations for sling and complications,
279 for sling and complications and bladder, and 68 for sling and complications
and voiding dysfunction. The reported complication rates ranged from
4.3% to 75.1% for retropubic and 10.5% to 31.3% for transobturator mid
urethral slings. Complications included bladder perforation, hemorrhage,
bowel injury, vaginal extrusion, de novo urgency and urge incontinence,
urinary tract infections and voiding dysfunction. Retropubic mid urethral
slings led to a higher occurrence of complications such as bladder perforation
and hematoma. In addition, the retropubic approach resulted in serious
complications such as bowel injury, major vascular injury and death.
Groin pain was more common after the transobturator approach. Experimental
studies indicated that the potential mechanisms for sling complications
may include vaginal dissection, denervation injury and bladder remodeling.
Conclusions: Mid urethral slings result in bothersome complications
which should not be minimized. Awareness of these complications should
encourage improvements in patient counseling as well as further investigation
of the underlying mechanisms. Decreasing complications should be considered
an important outcome for future clinical studies of mid urethral slings.
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Editorial
Comment
A noted authority in the field presents a broad spanning review of
potential complications of what has probably become the most popular
method of treating female stress urinary incontinence. Though the
authors did not report any instances of bowel perforation with a transobturator
sling, our institution is preparing a case report on a colon injury
associated with a transobturator tape procedure so this complication
may and does occur. If history serves as a guide, with the increased
used of mid urethral slings the breath and depth of complications
reported will expand. Of note is the somewhat high rate of new onset
urinary urge incontinence associated with a retropubic mid urethral
sling. This relatively high rate of urinary urgency was previously
noted in the past when reviewing the work of Alperin et al (1). This
rate of de novo urgency should be taken in historical context and
compared to discussions on this occurrence in the past (2).
References
- Alperin
M, Abrahams-Gessel S, Wakamatsu MM: Development of de novo urge incontinence
in women post sling: the role of preoperative urodynamics in assessing
the risk. Neurourol Urodyn. 2008; 27: 407-11.
- McGuire
E: Bladder instability and stress incontinence. Neurourol Urodyn. 1988;
7: 563-7.
Dr.
Steven P. Petrou
Professor of Urology, Associate Dean
Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu
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