Unrecognized bladder perforation with mid-urethral slings

Abstract

Objective: To present a series of women with late presentation of mid-urethral synthetic slings perforating the bladder and their management, this is rare but can lead to significant morbidity with medico-legal consequences.

Patients and methods: We retrospectively reviewed the case notes of nine women with urinary symptoms referred to our unit for further investigation after synthetic mid-urethral sling placement.

Results: The women presented between 8 weeks and 18 months after initial sling placement. Eight patients underwent a tension-free vaginal tape insertion via the retropubic route and one patient had an 'outside-in' obturator sling with the I-Stop device (CL Medical, Lyon, France). The frequencies of presenting symptoms were: dysuria in six; recurrent urinary tract infection in four; frequency and urgency in four and pelvic pain in two. Seven of the nine women developed bladder calculi on the exposed sling material, all of which were visible on plain X-ray. In six women, perforations were present at more than one site; in three urethral perforation had occurred together with an anterolateral bladder injury and in the remaining three there was bilateral bladder perforation. Initial management included cystoscopy and cystolithopaxy followed by transurethral resection (TUR) of the visible prolene mesh into the detrusor muscle. One woman required two TURs to clear all the mesh. Two women required further open surgery to remove all of the remaining mesh, both for ongoing pelvic pain that resolved after revision surgery. All the women had resolution of symptoms but all had recurrent stress urinary incontinence after tape division/excision. We used a novel technique to remove intraurethral mesh using a nasal speculum urethrally and excising the tape under direct vision, where resection proved impossible due to poor endoscopic views, with significant risk of sphincter injury.

Conclusions: The possibility of unrecognized tape perforation or erosion must be considered in women with persistent urinary symptoms, infection or pain after any form of mid-urethral sling procedure. Bladder stones almost invariably develop if the exposed mesh has been present for >3 months. Most patients can be managed with endoscopic resection to remove all intravesical tape. Cystoscopy should remain a mandatory procedure together with any form of mid-urethral sling placement but does not prevent unrecognized perforations in inexperienced hands.