REOPERATION AFTER COMPLICATED TENSION-FREE VAGINAL TAPE PROCEDURES

Abstract

A 42-year-old woman was admitted to the hospital with intermittent gross hematuria 1 week in duration, urinary frequency and lower abdominal pain that began 6 months after surgery. She had a history of proved stress incontinence and had been successfully treated with the tensionfree vaginal tape procedure 8 months earlier. Cystoscopy during the primary procedure had not been performed. On physical examination the bladder was mildly tender and the gynecological examination did not reveal any changes. Transabdominal and transvaginal ultrasound was normal. Laboratory evaluation revealed gross hematuria and urine cultures did not yield bacteria. Cystoscopy showed a proliferative lesion with calcifications on the left lateral bladder wall. The lesion was biopsied and afterwards a number of sutures were identified protruding into the lumen of the bladder. Histopathology demonstrated planocellular epithelial focal metaplasia and focal papillomatosis. Attempts to cut and remove these structures with endoscopic scissors and forceps was useless. Transabdominal exploration was performed (fig. 1). With the patient under general anesthesia a lower medial incision was made. A Foley catheter was inserted transurethrally to control urethral and bladder neck position. Following the course of the tape the bladder wall was localized and the lesion point with tape fixed to the wall was excised (fig. 2). Tape was incised bilaterally, simultaneously a U shaped sling under the mid urethra was palpated transvaginally and no changes in its position (no lowering) after cutting the tape were observed. Abdominal ends of the sling were cut, shaved and fixed bilaterally to the inguinal ligaments with 3 interrupting sutures on each side using 1-zero polydioxanone. The sling had optimal tension and the urethra was not elevated after fixation. Histopathological examination of the excised tensionfree vaginal tape with the connective tissue revealed granulomatous inflammatory infiltrate. The patient was discharged home. She was continent without the catheter and had no complications, such as hematuria, infection or voiding disturbances. The patient received a standardized Accepted for publication April 27, 2001.