Sling Complications Research Articles

Comparison of late complications of retropubic and transobturator slings in stress urinary incontinence

To compare the late complication profiles between retropubic and transobturator slings used for stress urinary incontinence was the objective of the study. Between the years 2003 and 2010, 338 complications of midurethral slings were surgically managed in a tertiary referral center. For the purpose of study, we excluded slings that had materials other than monofilament polypropylene, patients with previous anti-incontinence surgeries, and patients who were suspected of having a neurologic bladder condition. This is a prospective and retrospective study of the complications of midurethral slings. The characteristics of complications in retropubic and transobturator routes were compared and analyzed. Two hundred eighty cases with midurethral sling complications were suitable for analysis. Of these, retropubic slings constituted 210 and transobturator 70. The time interval between the insertion of tape and onset of complications was similar in both groups. Within the two groups, obstructive symptoms were seen more frequently in the retropubic tapes group. Compared to the retropubic tapes group, the transobturator group had more number of complications related to persistent pain (10% tension-free vaginal tapes vs. 32% transobturator tapes), dyspareunia (3% vs. 18%), and tape-related infections (4% vs. 18%). There were no significant differences among the complication rates pertaining to de novo overactive bladder (49% vs. 44%), obstructive symptoms (48% vs. 30%), and contraction of sling material (5% vs. 8%). Obstructive complications were seen more commonly in the retropubic tapes compared to the transobturator tapes. Transobturator tapes were more frequently associated with persistent pain, dyspareunia, and tape-related infections as compared to retropubic tapes.

Managing complications of slings

As newer materials and less invasive techniques emerge, treatment of stress urinary incontinence has increased over time. This shift has implications for the types of complications seen in contemporary practice compared to those even a few years ago. This review details prevention, diagnosis, and treatment of complications of sling surgery for stress urinary incontinence. Proper diagnosis and evaluation of stress urinary incontinence remains paramount in preventing surgical complications. Intraoperative complications, primarily bleeding and urinary tract injury vary depending on surgeon experience, operative technique and approach as well as prompt recognition of the injury. Postoperative complications include but are not limited to voiding dysfunction, urinary retention, vaginal extrusion and urinary tract erosion, thigh pain, and sexual dysfunction. Treatment relies on appropriate identification of the complication and may involve conservative and/or eventual surgical measures. As surgical treatment of stress incontinence evolves, thorough understanding of sling surgery and its attendant complications remain critical for the practicing physician.

Complications of mid-urethral slings for treatment of stress urinary incontinence

Objective To compare the incidence of complications associated with the use of retropubic tension-free vaginal tape (TVT) and transobturator tension-free vaginal tape (TVT-O) for the management of stress urinary incontinence (SUI). Methods In a cross-sectional study, 1081 patients were treated for SUI via mid-urethral slings, and the outcomes of those treated via TVT and those treated via TVT-O were compared. Patients who suffered from recurrent or mixed urinary incontinence were excluded. Results Group 1 included patients treated via TVT (n = 207) and group 2 included those treated with TVT-O (n = 570). There was a higher incidence of bladder perforation (5.4% versus 0.6%; P = 0.001) and hematoma formation (9.1% versus 1.5%; P = 0.001) in group 1 than in group 2. Compared with group 1, there was higher incidence of vaginal wall perforation in group 2 (0.0% versus 3.8%, P = 0.044). The rate of intraoperative complications was not related to patient age, body mass index, or parity. Of the patients who did not leak urine during a cough test 1 month after surgery, 90.9% still had a negative cough test at the long-term follow-up. Conclusion TVT-O was superior to TVT with regard to the incidence of bladder perforation and hematoma formation, but it resulted in more vaginal wall injuries.

Complications of the AdVance Transobturator Male Sling in the Treatment of Male Stress Urinary Incontinence

Complications of the AdVance Transobturator Male Sling in the Treatment of Male Stress Urinary Incontinence

To sling or not to sling at the time of anterior vaginal compartment repair

Prevention of postoperative stress urinary incontinence at the time of prolapse repair is controversial. There has been a shift away from colposuspension procedures to midurethral slings. As with any surgery, midurethral slings are associated with risks, which must be balanced against the benefits of preventing postoperative stress urinary incontinence. The aim of this overview is to review the controversy, discuss potential complications of midurethral slings, discuss the efficacy of concomitant sling placement, and suggest a method of systematically approaching patients with high-grade anterior compartment prolapse. Several studies have recently advocated for the routine use of anti-incontinence procedures at the time of prolapse surgery; however, applying these data to midurethral slings is problematic. Ultimately, the issue of treatment of the urethra at the time of prolapse repair should be discussed with the patient with treatment rendered depending on the risk the patient is willing to bear. The aim of this study is to discuss the risks and benefits of applying a midurethral sling in patients with high-grade anterior compartment prolapse. In these patients, placement of a suburethral sling may be approached systematically, taking into account the patients' variables and their own goals of therapy.

Outcome and Complications of Retropubic and Transobturator Midurethral Slings Translated into Surgical Therapeutic Indices

A number of studies have demonstrated that retropubic and obturator tape procedures are equally effective for cure of female stress urinary incontinence at 1 year after surgery. The use of the concept of risk/benefit in incontinence surgery is similar to pharmacology where the therapeutic index represents the ratio of desired effect to toxic effect. The surgical therapeutic index (STI) is the ratio between the cure and complication rate, with a high STI indicating greater safety. The aim of this retrospective cohort study was to determine and compare STIs of the retropubic tension-free vaginal tape (TVT) and 2 transobturator tape (TOT) procedures (Monarc and tension-free vaginal tape obturator [TVT-O]). Between 1998 and 2006, data was collected and analyzed for 237 patients with predominately female stress urinary incontinence, who underwent TVT (n = 257), Monarc (n = 95), or TVT-O (n = 85) procedures in a teaching hospital in the Netherlands. STIs were calculated for both groups by dividing cure by complication rate. The STI data for Monarc and TVT-O were presented as one combined group (TOT). Patients were followed for 2 and 12 months after surgery. At the 2-month follow-up, the STI in the TOT group was significantly higher than the TOT group (P < 0.05). After 12 months, however, no significant differences between the STIs in these groups were found. The similarity of STIs at 12 months was apparently due to longer lasting cure rates in the TVT group (P = 0.029) and an increased complication rate in the TOT group. These findings show that the benefit/risk of TVT and TOT based on the STI favors TOT in the short-time, but long-term results are similar among both groups. Both surgical procedures appear to have their own benefits and patients can choose between these two approaches.

Complications of the AdVance Transobturator Male Sling in the Treatment of Male Stress Urinary Incontinence

To evaluate prospectively the complication rate of the retrourethral transobturator sling (AdVance sling) for the functional treatment of male stress urinary incontinence (SUI). In 230 patients with SUI due to nonintrinsic sphincter deficiency (without direct sphincter lesion) after radical prostatectomy (n=213), radical cystoprostatectomy with ileal neobladder (n=2) and transurethral resection of the prostate (n=15) a retrourethral transobturator sling was implanted. Patients were followed up for a median of 17 months (range, 4-42 months) with regard to intraoperative, early postoperative, and midterm postoperative complications. Overall complication rate of the AdVance sling was 23.9%. Despite one accidental sling misplacement, no intraoperative complication occurred. Forty-nine patients (21.3%) experienced urinary retention postsurgery. Two slings were explanted (0.9%), 1 due to initial wrong placement and the other due to a symphysitis, attributed to a Guillain-Barré syndrome and not to a sling infection. One sling was transected (0.4%) due to slippage of the sling with obstruction of the urethra. Further complications were local wound infection (0.4%), urinary infection with fever (0.4%), and persistent moderate perineal pain (0.4%). There was no correlation between postoperative acute urinary retention and age at sling implantation, time of incontinence before sling implantation, preoperative daily pad use, or prior invasive incontinence treatment, respectively. The retrourethral transobturator AdVance sling is a safe treatment option for male nonintrinsic sphincter deficiency SUI, with the main postoperative complication being transient acute urinary retention. Severe intra- and postoperative complications are rare and sling explantation rate is very low.

Outcome and complications of retropubic and transobturator midurethral slings translated into surgical therapeutic indices

We sought to determine and compare surgical therapeutic indices (STIs) of the retropubic tension-free vaginal tape (TVT) and 2 kinds of transobturator tape (TOT), Monarc (American Medical Systems, Minneapolis, MN), and tension-free vaginal tape obturator. This was a retrospective cohort study. Patients with predominant stress urinary incontinence who underwent retropubic (TVT, n = 257) or TOT (n = 180) procedures were included. STIs for both groups were calculated by dividing cure by complication rate at, respectively, 2 and 12 months. Two months after surgery the STI was significantly higher after TOT whereas 12 months after surgery results of STIs were equal. The explanation is more durable cure rates and declining long-term side effects after TVT procedures. Both surgical approaches seem to have their own benefits. Based on the STI, the balance between cure rate and complications is on the short term in favor of TOT but on the long term similar for TOT and retropubic TVT.

Female urology: What method will you select?

When I was a resident, my leader taught me that the gold standard forpatients with stress incontinence is the Marshall–Marchetti–Krantz(MMK) procedure. But a few years later, urologists who could performadvanced techniques showed me needle suspension as the best methodat a urological meeting. Fortunately my boss gave me a chance for ahand-to-hand lesson of the stamay procedure by the specialist. Sincethen, I have been selecting this procedure for a few years. Withoutdoubt, this needle suspension was the gold standard at that time.But now most urologists do not select this technique because of badresults. After I had mastered the technique of tension-free vaginal tape(TVT), I could see the smiling faces of patients after the operation. Atthat time I believed that TVT would be the gold standard for thiscondition. But the present status is what you know.Recently most specialists, including myself, believe that using‘mesh’ is the best operation for patients with pelvic organ prolapse. Isthis tendency good for the patients in the long run? No one can predictthe results of this procedure more than ten years from now.God knows what procedure will be the gold standard in the future.Assistant Professor Yasuyuki Suzuki

Surgical Resection for Suburethral Sling Complications After Treatment for Stress Urinary Incontinence

Suburethral tapes have been widely adopted to treat stress urinary incontinence. Further resection of such tapes may be necessary in certain cases. We review our experience and assess urinary functional outcomes. We retrospectively reviewed the data on all women referred to our institution between 2001 and 2007 for suburethral tape related complications and on those who had the tape surgically removed. Complete or partial resection was achieved after assessment, including endoscopic and urodynamic assessment. A total of 75 women with a mean age of 60.7 years (range 28 to 78) were included in the study. The tape used was transvaginal in 58 cases (77.3%) and transobturator in 17 (22.7%). There were different complications, such as erosion in 16% of cases, vaginal extrusion in 24%, bladder outlet obstruction in 45%, chronic pelvic pain in 21%, and de novo urinary incontinence and urgency in 12%. Resection was done a mean +/- SD of 33 +/- 22 months (range 6 to 80) after tape placement. Of the 58 women with transvaginal tape the tape was completely removed by laparoscopy in 30 (51%). Four of the 17 transobturator slings (23%) were completely removed by laparoscopy (1) and via a low gynecological approach (3). The remaining slings were partially resected via a gynecological approach. At a mean followup of 38.4 months (range 12 to 72) incontinence recurred in 39 women (52%) after partial (18) and complete (21) resection. In rare women who experience crippling symptoms after suburethral sling implantation urologists must be aware that the decision to completely or partially resect the tape can help resolve symptoms.

Procedimiento Cabestrillo Autólogo versus Sintético: Tasa de éxito y frecuencia de obstrucción del tracto urinario inferior

Voiding dysfunction and urinary retention were frequent complications of sling. More recently synthetic supplies such as polypropylene mesh have been included in the armamentarium for sub urethral support. A prospective non randomized study was conducted. Sling procedure was performed in 436 consecutive patients with SUI. Patients were divided in groups according to mesh type, being 210 on autologous and 226 on synthetic. Patients were surveyed on voiding condition, continence and satisfaction. Surgical results were assessed according to Blaivas classification. Results were considered significant p<0.05. Mean patient age was 48.4 years. Mean operative time for autologous sling was of 107.6 min versus 20.6 min for synthetic. Mean hospitalization was 36h on autologous versus 24h on synthetic and mean follow up was 25 months. We found 87.1% and 92.9% of patients continent in autologous and synthetic group, respectively. Failure was presented by 7% in autologous and 4.8% in synthetic group (p=0.1961). The global rate of BOO was of 4.5% (20/436), when analysed by groups we found on autologous a rate of 8.5% (18/210), compared to 0.9% on synthetics (2/226) (p=0.000126). Autologous and synthetic slings presented comparable success rates, however BOO was more common among patients treated by autologous slings.

Procedimiento Cabestrillo Autólogo versus Sintético: Tasa de éxito y frecuencia de obstrucción del tracto urinario inferior

ObjectivesVoiding dysfunction and urinary retention were frequent complications of sling. More recently synthetic supplies such as polypropylene mesh have been included in the armamentarium for sub urethral support. MethodsA prospective non randomized study was conducted. Sling procedure was performed in 436 consecutive patients with SUI. Patients were divided in groups according to mesh type, being 210 on autologous and 226 on synthetic. Patients were surveyed on voiding condition, continence and satisfaction. Surgical results were assessed according to Blaivas classification. Results were considered significant p<0.05. ResultsMean patient age was 48,4years. Mean operative time for autologous sling was of 107,6 min versus 20,6min for synthetic. Mean hospitalization was 36h on autologous versus 24h on synthetic and mean follow up was 25 months. We found 87,1% and 92,9% of patients continent in autologous and synthetic group, respectively. Failure was presented by 7% in autologous and 4,8 % in synthetic group (p=0.1961). The global rate of BOO was of 4,5 % (20/436), when analysed by groups we found on autologous a rate of 8.5% (18/210), compared to 0.9% on synthetics (2/226) (p=0.000126). ConclusionsAutologous and synthetic slings presented comparable success rates, however BOO was more common among patients treated by autologous slings.

Thigh abscess mistaken for sarcoma following transobturator tape: A case report and literature review

A 44-year-old female, 1 year status-post ObTape transobturator mid-urethral sling, was evaluated by orthopaedic oncology and urology for persistent thigh pain and a left thigh mass. Multiple muscle biopsies were inconclusive, raising concern for inflammatory sarcoma. After serial débridements of the thigh abscess, sling material was found in the obturator space, which gave the diagnosis. Health care providers, both gynecologic and nongynecologic, need to be aware of serious complications of transobturator slings that may present in atypical ways.

What??s new in slings: an update on midurethral slings

Surgical management of female stress incontinence has progressed rapidly over the past decade. The purpose of this review is to provide up-to-date information regarding surgical outcomes of midurethral slings and to discuss management of sling complications. Additionally, the newer commercially available products will be outlined and the data comparing new versus established techniques will be examined. Long-term data are available for the Tension-free Vaginal Tape procedure which demonstrates durable efficacy. Comparisons between the Tension-free Vaginal Tape and Suprapubic Arch sling procedure demonstrate no significant difference in cure rates or complications. In an effort to avoid the retropubic space, the transobturator slings were developed and short-term data suggest similar efficacy to the transabdominal techniques. The transobturator approach, while limiting abdominal complications, is not without its own complication profile. Increased experience with synthetic mesh in vaginal surgery has allowed for a more systematic approach to managing mesh erosions. The literature indicates that midurethral slings, despite the specific approach, are efficacious and an important therapy in managing stress incontinence. Prospective data will be needed before the surgeon can determine if the new products and techniques are truly an improvement over the existing products or merely a proprietary modification.

Comment on Karsenty et al.: Severe soft tissue infection of the thigh after vaginal erosion of transobturator tape for stress urinary incontinence

Dear Editor, In this important paper [1], the authors report on a lifethreatening complication from transobturator tape slings, primarily due to poor biocompatibility of a particular synthetic sling material. In addition to recommending the method of treatment (total removal of the sling), the authors recommend this material should not be used for transobturator slings and that, in view of the serious complications that have resulted from insertion of incompatible biomaterials, more serious evaluation should be formed before clinical use is acceptable. In a similar vein, Deng et al. [2] report their experience dealing with serious complications of suburethral slings and, in addition, perform a literature search as well a review of the FDA database. The authors dealt with a series of 26 patients with bladder and/or urethral erosions. In many cases, diagnosis was delayed because patients were treated with watchful waiting and conservative treatment rather than early cystoscopy. Furthermore, the authors make the case that there is a need for a registry for each type of sling and sling material to have a better understanding of the frequency and complication rate from the procedures and materials. In addition, the authors also note that, in Finland, there is a systematic nationwide training program for performing tension-free vaginal tape (TVT) (not mentioned is that the country also monitors every surgeon’s TVT results, requiring retraining and possible restrictions if the surgeon’s results are not acceptable). Just from these two papers, it is apparent that more needs to be done to protect patients. This comes up at professional meetings time and time again. How many more patients need to be harmed before action is taken? This requires a collaborative effort. Regulatory agencies must evaluate biomaterial compatibility more stringently and vigorously monitor results after approval. Industry must do its part to adequately evaluate biomaterials. Professional medical organizations need to work hand-in-hand with industry and regulators in regard to these matters, and surgeons need to be sure there is proper training and monitoring for patient safety. Enough papers have been written; enough meetings have discussed these issues. It is now time for action, and professional medical organizations need to take the lead.

Presentation and management of major complications of midurethral slings: Are complications under‐reported?

Midurethral slings have become the mainstay of stress urinary incontinence (SUI) treatment due to their efficacy and low complication rates. The purpose of this study was to report the presentation and treatment of major complications from these minimally invasive treatments presented to a tertiary referral practice and to highlight a discrepancy in major complications between literature and the food and drug administration (FDA) device failure database. From 2001 through 2005, we reviewed all cases of midurethral sling complications that presented to our institution. A literature review of all complications due to midurethral slings during the same time period was performed as was the FDA manufacturer and user facility device experience (MAUDE) database queried for self-reported complications. A total of 26 patients referred to UCLA with voiding dysfunction after sling placement was found to have mesh in the urethra or bladder. Treatments required a combination of urethrolysis with mesh removal, urethral reconstruction with graft, and bladder excision. These were compared to major complications reported in the world literature of <1%. The MAUDE database contained 161 major complications out of a total of 928 complications reported for suburethral slings. There was significantly more major complications reported in MAUDE than in published literature. Although rare, major complications of midurethral slings are more common than appear in literature. Devastating complications involving urethral and bladder perforations can present with mild urinary symptoms and thus are likely under-diagnosed and under-reported. Most of these cases need to be managed with additional reconstructive surgery.

The Long-Term Results of Pubovaginal Sling Surgery Using Acellular Cross-Linked Porcine Dermis in the Treatment of Urodynamic Stress Incontinence

Acellular cross-linked porcine dermis is a potential substitute for rectus fascia as a sling material with the advantage of decreased morbidity. However, the long-term efficacy is unknown. We compared the 3-year efficacy of PD vs autologous rectus fascia as a sling material for pubovaginal sling surgery in the treatment of urodynamic stress incontinence. Between July 2000 and December 2001 a total of 101 consecutive, nonrandomized patients with USI underwent a PD (51) or RF (50) sling procedure. Patients were assessed at 6 weeks, and at 3, 6 and 12 months postoperatively. Urodynamic study was repeated in cases of treatment failure. A detailed survey questionnaire was mailed to all patients at least 36 months after surgery and all responders were then retested by telephone interview by a blinded assessor. The primary outcome measure was patient perceived success rate (cured or improved) at least 36 months after PVS. Secondary outcome measures were patient satisfaction 36 months after surgery, durability of success with time and reoperation rate. Complete data were available on 94 patients (48 treated with PD and 46 treated with RF sling). The groups were well matched for age, leak point pressure, prior incontinence surgery and urge symptoms. Pubovaginal sling was successful (cured or improved) in 37 (80.4%) patients treated with RF but in only 26 (54%) patients treated with PD 36 months after surgery (Fisher's exact test p = 0.009; 95% CI 8.03, 44.4). Treatment failure occurred by 9 months after RF and by 24 months after PD sling procedure. Repeat urodynamic study showed USI to be the cause of treatment failure in 18 (37.5%) of 20 patients treated with PD but in only 3 (6.5%) of 8 patients treated with RF. We have shown that use of the PD sling, although reducing early morbidity, results in a significantly inferior long-term cure rate in comparison to the RF sling. Therefore, acellular cross-linked porcine dermis should not be used as a substitute for rectus fascia.

Bladder wall abscess following midurethral sling procedure

Midurethal sling procedures are gaining popularity as the treatment of choice for stress urinary incontinence. Complications that were described include bladder perforation, urinary retention, pelvic hematoma and suprapubic wound infection. Sling erosion and pelvic abscess are rare complications of midurethral slings. We report the first case of an abscess formed within the wall of the urinary bladder, 7 months following a midurethral sling procedure.

Rising awareness of the complications of synthetic slings

This article will review the current literature on the complications of synthetic suburethral slings used in the treatment of stress urinary incontinence and the management of these complications. Loosely applied mid-urethral synthetic slings are becoming the treatment of choice in the management of stress urinary incontinence. Despite the ease of carrying out these procedures there is still a learning curve and, whilst the current literature shows there has been a significant reduction in the complication rate in recent years with the use of modern synthetic slings, they still occur and can be a significant cause of morbidity. There has been interest in developing better imaging techniques for both establishing early diagnosis and in assisting in the treatment of complications; magnetic resonance imaging of the urethra has been one of the modalities that has been investigated. Further work is needed to predict those who are more likely to develop complications during the placement of suburethral slings; the use of urodynamic procedures has shown equivocal results. Inevitably with more experience the techniques have evolved for the management of complications, such as the treatment of urethral obstruction with transvaginal sling incision. Synthetic materials for slings provide an effective and safe method for treating urinary stress incontinence in women, and have delivered improved efficacy; nevertheless, although the incidence of complications has significantly reduced in recent years, they still represent a significant and not unsubstantial morbidity.

Complications of urethral sling procedures

To review the current literature on complications of suburethral slings used to treat stress urinary incontinence in the female. The surgical treatment of female urinary incontinence has changed considerably since the development of the tension-free vaginal tape procedure, introduced by Ulmsten in 1995. As the follow-up for the first studies is now more than 5 years, the 'long-term' results of the technique can be evaluated. Furthermore, now that the learning phase has been completed and the technique can be considered to be well mastered, it is interesting to review the complications inherent in this technique, their frequency, including those rarer complications that are sometimes associated with severe morbidity, and to consider the ways in which these complications can be prevented or treated. The development of the tension-free vaginal tape procedure has not prevented the development of other types of suburethral sling, but on the contrary, has promoted the development of these alternatives by the use of various sling insertion techniques, and especially various types of materials. There has even been a renewed interest in materials that have been known for a long time (heterologous and autologous materials) in some recent papers, and new synthetic suburethral slings have been proposed with the objectives of combining low morbidity, safety and efficacy. Monofilament polypropylene meshes can be used safely to perform suburethral slings and seems to be the most suitable material in this indication according to the existing literature.