RARE COMPLICATIONS OF TENSION-FREE VAGINAL TAPE PROCEDURE: LATE INTRAURETHRAL DISPLACEMENT AND EARLY MISPLACEMENT OF TAPE

Abstract

Case 1. A 48-year-old obese woman presented with severe pain at the end of voiding. Seven months earlier a tensionfree vaginal tape procedure had been performed for type 2 stress incontinence with moderate urgency.2 At presentation the patient was receiving prednisolone. On cystoscopy we found the bare polypropylene sling inside the lumen of the proximal urethra (see figure). The patient was operated on in the lithotomy position. A 2 cm. midline incision under the mid and proximal urethra was made through the anterior vaginal wall, underlying fascia and urethral mucosa. Inside the urethra the bare sling was cut on both sides at the level of mucosa. The urethral incision was closed in 2 layers with a 3-zero absorbable running suture. The area between the anterior vaginal wall and the remnants of the implanted sling was dissected with scissors until the inferior ramus of the pubic bone was reached. It was possible to cut the adherent sling at this level bilaterally and create a small passage through the periurethral fascia. Since the tissues were of poor quality, the urethral incision was covered with a Martius pedicled fat flap.3 Following the prepared route tension-free vaginal tape needles were used to place a second length of tape below the Martius flap covering the urethra. To keep the tape under the mid urethra the distal edge was secured with 1 absorbable suture to the periurethral fascia. The standard tensionfree vaginal tape procedure was then completed. Postoperatively spontaneous nonresidual voiding occurred within 2 days. The patient was completely stress continent with occasional nocturnal urge incontinence 8 months later. Case 2. A 37-year-old woman underwent a tension-free vaginal tape procedure for type 2 stress incontinence. Following the standard method cystoscopy was performed after placement of the needles but before removal of the covering sheets. Immediately after the procedure hematuria occurred and urine drained from the vaginal incision. On cystoscopy the bare tape sling could be seen inside the lumen of the proximal urethra. The midline vaginal incision was reopened, the sling was cut outside the urethra, and both ends of the sling could be pulled out easily through the mid vaginal wound. A 2 3 cm. patch of cadaveric fascia lata femoris was placed between the urethra and the new tape sling, which was fixed to the mid urethra with 1 distally applied 3-zero absorbable suture. A urethral catheter was left indwelling for 7 days. Thereafter the patient had nonresidual voiding and was continent 5 months postoperatively. The cause of both complications was possibly placement of the sling too proximal with too much tension after too deep a dissection. These cases show that even for a second time, tension-free vaginal tape was still rather easy to introduce with low morbidity. However, we consider it crucial to have a layer of healthy tissue between the urethra and the polypropylene sling. If healthy tissue is not available interposition of cadaveric fascia or in severe cases a Martius flap can be used.