Late complications after intravaginal slingplasty for female stress urinary incontinence

INTRODUCTION ANDAIMOF THE STUDY:Wereport two cases of late complications after Intra-Vaginal Slingplasty, (IVS) procedure for female stress urinary incontinence (FSUI). The first patient had a suprapubic abscess at two and then at six years after surgery. The second patient had a bilateral paraurethral anterior vaginal wall abscess. These cases suggest the importance of a long follow-up in allwomen who underwent a sub-urethral sling procedure for FSUI. MATERIALS AND METHODS: Case 1: a fifty-one-year-old woman, presented with an increasing suprapubic pain mainly on the right side, and a local swelling. Patient’s past history was as follows: two cesarian births, hyperthyroidismin pharmacological treatment, smoker, no allergy. Because of increasing FSUI till her second delivery, she underwent IVS implant in 2004, in a Gynecologic unit.After surgery she referred wellness, no more FSUI. In 2006 she complained of fever, suprapubic painful swellingmass, with a vaginal protrusion of the sling at physical examination. It was treated removing a suprapubic abscess on the left side of the abdomen and the left part of the IVS sling by a vaginal approach in the above mentioned Gynecologic unit. Than she referred wellness till July 2010, when she complained of a painful soprapubicmass on the right side. At physical examination a mobile and painful mass 4 cm of diameter on the right side of the suprapubical region, was palpable, within the suprapubic fat, compatible with abscess. Genital examination was negative, vaginal wall and mucosa were regular, there was no evidence of FSUI. She underwent lower abdomen and trans-vaginal ultrasound (US) that reported an expansive liquid mass in the correspondence of the painful abdominal swelling mass within the subcutaneous fat tissue; it was moderately corpuscolar, mobile, with a serpiginous structure inside, to be referred to the branch of the sling. MRI reported a para-median right mass in the groin region, 3 cm transverse diameter; within the subcutaneous fat tissue. It was oval, with clear limitations, thick wall and partially homogeneous liquid content. There was a wall enhancement after contrast, and a communication with the lateral right vaginal wall through a small fistula. This fistula presented a strong post-contrast enhancement wall. Bladder and uterus were regular. By a small suprapubic traversal incision we removed a capsulated mass, 4 cm of diameter, surrounding the branch of the sling that emerged from the muscular fascia.The content was a yellow dense fluid material and the IVS mesh. Case 2: a fifty-nine-year-old woman, presented with recurrent cystitis, dyspareunia and vaginal discharge of purulent liquid mixed to hematuria. Her previous clinical history was silent. She underwent IVS positioning in a Gynecologic unit in 1993 because of FSUI. Four years ago she complained of frequent recurrent cystitis, important dyspareunia and vaginal discharge of purulent liquid mixed to gross hematuria; for that reason, she underwent multiple topic treatments, antibiotic therapy, and vaginal sutures of vaginal mesh erosionswithout any benefit. Sometimes she complained of hemorrhagic cystitis. At local examination, there were two superficial erosions at the anterior vaginal wall level, the sling was not visible, but a white purulent material came from the left side of the vagina and that area was painful at themanual palpation. At the endoscopic examination, there was an hyperemic area from hour 11 to 5 proximal to the bladder neck like a bubble edema. MRI reported an increased thickness of the inferior bladder wall. A thin fluid and a corpuscolar film under the urethra compatible with an inflammatory collection were detected. We removed the two parts of the sling through two small incisions in the anterior vaginalwall, at both sides to the median line. The mesh were surrounded by a purulent material that was cleaned with disinfectants. RESULTS: Both patients was discharged two days after the surgical procedure, we prescribed antibiotic therapy for seven days. At the visit after seven days from the discharge, the woundwas regular and the patients referredwellness. Actually at a follow up for 25 months of the first patient and 10 months for the second, they are totally asymptomatic. INTERPRETATION OF RESULTS: There are different types of surgical treatments for the management of FSUI: retropubic colposuspension, there are three variations of this procedure (Burch approach, Marshal-Marchetti-Krantz approach and paravaginal defect repair), pubovaginal slings, tension-free mid-urethral slings (TVT, TOT or TVT-O, IVS).Mid urethral sling procedures are ‘‘so-called’’ minimally invasive therapies but they are not aware of complications. Using a mid urethral sling the surgeon creates an artificial support for the mid portion of the urethra through the use of a narrow band of either autologous or syntheticmaterial, which suspends the patient’s urethra and helps to prevent the leakage of urine. It is a minimally invasive approach compared to the retropubic colposuspension, but there are surgical complications such as bladder perforations, pelvic hematoma and storage lower urinary tract symptoms. In our cases we report an abdominal abscess in the correspondence of the IVS sling, respectively at two years fromthe surgery at left side and six years at the right side, and multiple symptoms connected to the vaginal erosion of themesh at five years fromsurgery, lasted four years and not responding to topic treatments. In this type of surgery it is very important the type of mesh used. It is noted in literature that meshes in multifilament and small pores were often complicated by abscess or infection of the mesh.Actually the synthetic material that results in the best tissue incorporation is monofilament macroporous polypropylene mesh. However, as all synthetic slings are foreign bodies, different types of erosions and infections have been described. CONCLUSIONS:Wereport these cases to underline possible late complications of this type of surgery. It’s interesting that several episodes may happen during the time. The first patient had a complication at two and six years after surgery, and it was quickly diagnosed and treated because she continued follow-up. The second patients had recurrent cystitis, vaginal discharge of purulent material sometimes mixed to blood, frequent vaginal erosions despite surgical vaginal repairs. This case suggests the importance of a correct treatment of this kind of complications from the begging, mesh removal is the only most effective therapy, and the outcome is immediate. These cases suggest the important role of follow-up in all women that underwent a mid-urethral sling placement for FSUI also in those who don’t complain of FSUI after surgery, in order to avoid hidden complications. In cases of infective complications, mainly when associated with vaginal erosions it is important a quick mesh removal.