Tension-free Vaginal Tape Placement Research Articles

Case report of vaginal erosion and recurrence of stress urinary incontinence due to shallow placement of tension-free vaginal tape

BackgroundSuburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence (SUI). Erosion of the tape into the vaginal is rare. Very few patients present with vaginal tape erosion and recurrence of SUI.Case presentationA 49-year-old female patient with stress urinary incontinence was treated with a retropubic suburethral TVT sling. 2 months later, recurrent symptoms of SUI developed. 6 months later, the patient complained of repeated vaginal discharge and foreign body sensation. Body physical examination revealed a 1-cm-long tape extrusion at the left anterior vaginal wall beside the midline. Cystourethroscopy revealed no urethral mesh erosion. Surgical removal of the extrusion tape revealed that the left arm of the tape was in the vaginal mucosa layer rather than between the whole thickness of the vaginal mucosa and urethral. The tape around the urethral was dissected and removed. A new retropubic tape was placed simultaneously. At the 8-months follow-up after surgery, the patient was continent without tape vaginal exposure.ConclusionsVaginal mesh erosion should be considered in a patient who presents with sustained vaginal discharge after being treated with a suburethral sling. It is important to place the tape between the whole thickness of the vaginal mucosa and the urethral in SUI surgery. A shallow placement of the tape may lead to vaginal tape erosion and recurrence of SUI. These complications can be avoided by following the correct manipulation procedure and referring to the tissue layer anatomy.

Clinical Study of Combined Endoscopic And Percutaneous Management of a Late Complication Following Tension-free Vaginal Tape (TVT) Anchored Stone for Female Stress Urinary Incontinence

TVT is a simple and less-invasive variation of the suburethral sling with higher success rates1. It has beenrapidly gaining popularity worldwide but it has also lead to increasing number of patients presenting withassociated complications. Bladder erosion through the bladder wall occuring predominantly within the first2 years the placement of TVT is producing tension or in the close proximity of the bladder..Formation of acalculus in the urinary bladder secondary to an intravesical mesh erosion is relatively infrequent rare anddelayed complication.Owing to the scarcity of the data on mesh erosion there is no consensus regarding theideal approach to remove the mesh Combined endoscopic and percutaneous approach should be opted as thepreferred approach .Open surgery should be opted only if minimal invasive approach fails.

Internal herniation as a complication of tension-free vaginal tape implantation: A report of two cases

Tension-free vaginal tape (TVT) is often placed for stress urinary incontinence. A number of gastrointestinal complications following TVT placement have been previously described. Internal herniation through this pelvic mesh, however, has not yet been documented. Herein, we describe the presenting symptoms and operative management strategies of this rare complication. Two patients who presented to our institution were ultimately found to have internal herniation through TVT mesh and managed differently. Both patients presented complaining of unilateral sharp flank pain and were initially worked up for renal colic; computed tomography of the kidney, ureters, and bladder raised suspicion for small bowel obstruction. Both were taken to the theater. In one case, exploratory laparotomy revealed necrotic strangulated small bowel herniating through a defect in the TVT mesh. We performed small bowel resection and mesh explantation with postoperative return of urinary incontinence. In the other case, the hernia was reduced laparoscopically revealing noninfracted small bowel. The mesh defect was obliterated with interrupted sutures. Flank pain and symptoms of bowel obstruction with a history of TVT placement should prompt surgeons to consider internal herniation. The extent of ischemia and the need for small bowel resection are factors that should be considered when deciding whether to manage open or laparoscopically and whether to preserve or remove the mesh.

EP36.06: Transperineal ultrasound assessment of anatomical changes before and after surgery with tension‐free vaginal tape for stress urinary incontinence

To study changes in symptoms and bladder neck in women undergoing tension-free vaginal tape (TVT) surgery for stress urinary incontinence (SUI). Secondarily, to study any association between postoperative anatomy, TVT placement and symptoms. Prospective observational study of 65 women with SUI assessed on the day of TVT surgery and 6 months later. They answered yes/no to questions about SUI and urge urinary incontinence (UUI). Transperineal ultrasound was used to assess urethral funneling at Valsalva and abnormal bladder neck descent (BND) defined as > 25 mm descent from rest to Valsalva. The distance from the TVT to the bladder neck at rest and to the symphysis at Valsalva were measured. Any differences between pre- and postoperative symptoms and anatomy and any association between postoperative anatomy and SUI were tested with Fisher's exact, X2 or t-test. Mean (SD) age was 50 (9) years and BMI 26.3 (4.5) kg/m2. Table 1 compares symptoms and anatomy before and after surgery. 52/60 (87%) women were cured for SUI. Women with persistent SUI had similar postoperative anatomy and TVT placement as cured women: BND > 25 mm 0/6 (0%) vs. 4/51(8%), funneling 0/6 (0%) vs. 16/51 (31%), TVT distance from bladder neck 2.2 (0.7) cm vs. 2.1 (0.5) cm, and from symphysis 1.6 (0.3) cm vs. 1.5 (0.3) cm; all p > 0.05. TVT surgery had a high cure rate for SUI. Women with mixed incontinence had less UUI after surgery and funneling was significantly reduced. No association between persistent SUI, BND, funneling or TVT placement was found. Persistent SUI could be associated with other factors, such as hormonal status and intrinsic urethral pressure. EP36.06: Table 1. 65/65 100% 8/60 13% 38/65 61% 11/60 18% 13/65 20% 4/57 7% 25/65 39% 16/57 28% Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Retrospective review of intra- and post-operative complications with minimal versus large space of Retzius infiltration at the time of retropubic TVT placement.

A concern when using the retropubic tension-free vaginal tape (TVT) for stress urinary incontinence (SUI) is bladder perforation. This article describes a technique hypothesised to reduce the risk of intra-operative bladder perforation, termed the large space of Retzius infiltration (LSORI) technique. A large volume of infiltration of 360ml saline-vasoconstrictor solution (180ml × 2) into the space of Retzius (LSORI) at the time of retropubic TVT insertion will reduce the incidence of intra-operative bladder perforations. This was a retrospective study reviewing the medical records of 89 women who underwent the retropubic TVT procedure at two urogynaecology Units. The intra- and post-operative characteristics associated with minimal (MSORI) versus large retropubic space of Retzius infiltrations (LSORI) were examined. Eighty-nine patients undergoing SUI surgery met the inclusion criteria. Forty-one patients had MSORI (volume range 20-60ml bilaterally) versus 48 who had the 180-ml bilateral LSORI. No bladder perforations (0%) occurred in the LSORI group versus four in the MSORI group (9.8%), found to be statistically significant (p = 0.013). All other outcomes examined had no statistical difference. The TVT-related pain incidence: 8.3% (LSORI) versus 9.8% (MSORI). Post-operative urinary retention incidence was 6.3% (LSORI) and 14.6% (MSORI). Retropubic haematoma incidence was 0% (LSORI) and 2.4% (MSORI). Post-operative UTI rate was 12.5% (LSORI) and 17.1% (MSORI). This retrospective review revealed the potentially beneficial effect of the large (180ml × 2) bilateral SORI with retropubic TVT placement in terms of the reduction in risk of bladder perforation. It also showed no potential added risk of post-operative complications.

Endoscopic holmium laser management of tension-free vaginal tape eroded into the bladder

Tension-free vaginal tape (TVT) procedure is not free from intra- and postoperative complications. Diagnosis of mesh erosion is often underestimated by clinicians due to its unspecific symptoms. Urinary symptoms not responding to medical therapy should be investigated by cystoscopy to exclude mesh erosion. We report our experience with holmium laser for the endoscopic management of mesh erosion in three patients. We describe three cases of mesh erosion after TVT placement treated with laser excision of the eroded tape into the bladder. In one case, a 4 × 3 cm stone adhering to the mesh was present. The procedures were performed under spinal anesthesia. The polypropylene eroded mesh was mobilized with forceps to better expose the intramural portion of the sling, and it was disintegrated with holmium laser as close to the bladder mucosa as possible. No complications were recorded. The patients were discharged after 24 h. In only one case, we had recurrent mesh exposure requiring a second procedure. After a mean follow-up of 15.3 months (range 12-20), the patients are asymptomatic with no evidence of tape erosion. Intravesical mesh erosion can complicate sling procedure. Endoscopic holmium laser management is a useful treatment for mesh removal and stone lithotripsy. Repeated treatments are possible for the low morbidity and minimal invasiveness. A regular follow-up is necessary.

Étude comparative entre deux procédures de mise en place d’une bandelette sous-urétrale rétropubienne TVT dans le traitement de l’incontinence urinaire d’effort féminine

To evaluate complications and functional outcomes at 1 year and more of a modified Tension-free Vaginal Tape (TVT) technique from that of classic TVT. Retrospective study comparing the two techniques. For the modified TVT technique, a peri-urethrovesical hydrodissection was performed. An 18-gauge hollow needle, in which a thread was introduced, was used as an ancillary for the placement of the sling. The sling was secured to the thread and then positioned with it. Bladder filling objectified perforations. An absorbable suture around the sling allowed its descent if necessary. One hundred and eighteen procedures were performed (54 classic TVT and 64 modified TVT). For the standard TVT and the modified TVT, the vesico-urethral perforation rates were respectively 7.4% and 1.5% (P<0.05), those of reoperations for pulling the sling downward 11.1% and 1.5% (P<0.05). A 1 year and more, healing and satisfaction rates were respectively 83.3% and 79.2% for the standard TVT versus 88.2% and 90% for the modified TVT (NS). The dissatisfaction rate was lower for the modified TVT (P<0.05). By modifying the placement of the classic TVT, it is possible to reduce its complications while maintaining its efficacy.

Solifenacin in Women with De Novo Overactive Bladder after Tension-Free Obturator Vaginal Tape—Is it Effective?

To our knowledge no group has evaluated antimuscarinic efficacy in patients with de novo overactive bladder after mid urethral sling placement. We assessed solifenacin efficacy in women with de novo overactive bladder after obturator tension-free vaginal tape placement compared to a control group. We prospectively considered all women with de novo overactive bladder symptoms at a 3-month followup visit after placement of obturator tension-free vaginal tape. Patients with overactive bladder preoperatively and those with obstructive symptoms or signs were excluded from analysis. Women who satisfied inclusion and exclusion criteria (group 1) were compared with a series of consecutive naïve patients with overactive bladder symptoms without a previous surgical procedure for stress urinary incontinence (group 2). We prescribed 12-week antimuscarinic therapy with oral solifenacin 5 mg once daily. Objective outcomes included changes from baseline in 3-day voiding diary data. Subjective efficacy was evaluated using the Overactive Bladder Questionnaire Short Form, Urgency Severity Scale and Patient Global Impression of Improvement questionnaires. A total of 110 patients with de novo overactive bladder after obturator tension-free vaginal tape placement completed solifenacin treatment and were included in group 1. They were compared with 120 consecutive naïve women with overactive bladder (group 2). Group 1 presented at the 3-month followup visit with significantly less benefit in the mean decrease in urgency and urgency urinary incontinence episodes daily (-1.1 vs -2.3 and -0.2 vs -1.1, respectively, each p <0.0001). In group 1 we also found a lower subjective solifenacin effect. Previous obturator tension-free vaginal tape placement was an independent predictor of failed solifenacin treatment. Antimuscarinic treatment with solifenacin had significantly lower efficacy in women with de novo overactive bladder after mid urethral sling placement than in controls.

Tension-Free Vaginal Tape Plus Intradetrusor BOTOX® Injection Versus Tension-Free Vaginal Tape Versus Intradetrusor BOTOX Injection in Equal-Weight Mixed Urinary Incontinence: A Prospective Randomized Study

Objective: The aim of this study was to determine the safety of the placement of tension-free vaginal tape (TVT) plus intradetrusor BOTOX® (onabotulinumtoxinA; Allergan, Inc., headquartered in Irvine, CA) injection, and the outcome after 12 months. Design: An open, prospective study was conducted on 93 patients presenting with stress and urgency urinary incontinence of the same severity from the patients' point of view. Materials and Methods: Subjects were divided into three groups: TVT+intradetrusor BOTOX injection (group 1); TVT only (group 2); or BOTOX injection only (group 3). At baseline, and at 1, 6, and 12 months, each patient was assessed by taking a medical history and performing a physical examination, including a cough test, a Q-Tip test, a 1-hour pad test, upper urinary tract sonography, postvoid residue, urinary analysis and culture, serum chemistry; and scores on the International Constellation on Incontinence Questionnaire (ICIQ)–Urinary Incontinence (UI), the ICIQ–Overactive Bladder (OAB), and the ICIQ–Quality of Life (QOL) instruments. Urodynamic studies, including filling cystometry, uroflowmetry, and abdominal leak-point pressure at baseline were performed. At a 1-month follow-up, cystometry and uroflowmetry were performed. Data were then analyzed using SPSS, Pearson's χ2, and Mann–Whitney U test. Results: The overall ICIQ-UI scores in group 1 declined from 15.4 to 2.5, 0, and 0, in 1, 6, and 12 months, respectively. In addition, ICIQ-OAB scores improved from an original mean baseline of 10.1 to 2.6, 0, and 1.1, in 1, 6, and 12 months, respectively. There was a significant improvement in urinary continence and, therefore, QOL for group 1 patients (p<0.05). ICIQ-UI and ICIQ-OAB scores showed remarkable improvement in patients who underwent the sling procedure (group 2) and the BOTOX injection (group 3), respectively (p<0.05). Nevertheless, the reverse did not occur. (There was insignificant change in ICIQ-OAB in group 2 and in ICIQ-UI in group 3). Retention occurred in 2, 0, and 2 patients in groups 1, 2, and 3, respectively, with no significant difference. Upper urinary-tract ultrasonography, urinary analysis and culture, and serum chemistry were normal in all patients. Conclusions: TVT plus intradetrusor BOTOX injection is a feasible and safe procedure. The results showed that there were subjects cured or with marked improvement at a 12-month follow-up. (J GYNECOL SURG 29:235)

Transvaginal Sling Release With Intraoperative Ultrasound Guidance

Visualization of a midurethral sling may be challenging intraoperatively, especially if the sling is deep, well healed, not in the usual location, or made of materials that are not colored. We present the case of a 71-year-old woman presenting with a history of incomplete bladder emptying and debilitating voiding dysfunction documented by uroflowmetry and postvoid residual after a tension-free vaginal tape placement. Medications in addition to attempts to dilate her urethra failed to provide her with adequate relief. Intraoperative 3-dimensional ultrasound guidance was used to transect the sling that was otherwise unable to be localized with examination alone. Surgical transection of a tension-free vaginal tape can be safely performed under the guidance of ultrasound. At her 12-month follow-up visit, the patient did not have urinary incontinence or voiding dysfunction.

A Randomized Comparison of Bupivacaine Versus Saline During Placement of Tension-Free Vaginal Tape

To compare postoperative urinary retention and pain control when bupivacaine versus saline for hydrodissection is used while placing tension-free vaginal tape midurethral slings. A prospective, randomized, double-blind trial was performed after institutional review board approval. Sixty women were randomized to receive bupivacaine or saline for hydrodissection. Subjects and research team were blinded to subject assignments. Group characteristics were compared using the Student t test, the χ test, and the Mann-Whitney U test. Proportions of subjects with a successful postoperative voiding trial along with measurements of postoperative pain and analgesic use were compared using similar appropriate tests. The study was powered to detect differences in voiding trial success from an estimated 58% to greater than 90% with P < 0.05 and 0.8 power using 25 subjects per group. Thirty patients were allocated to each group. One subject in the saline-only group was excluded. Group characteristics were not different. After surgery, pain medication use (20/30 vs 25/29 for bupivacaine vs saline only; P = 0.08), pain scores (36 ± 22 vs 31 ± 24; P = 0.49), and successful voiding trials did not differ (14/30 vs 19/29; P = 0.14), whereas postvoid residuals did differ (225 ± 180 mL vs 140 ± 147 mL; P = 0.043). Bupivacaine was not seen to improve immediate postoperative pain after placement of a tension-free vaginal tape. It did not increase the risk of failing a postoperative voiding trial. Without an obvious benefit, the use of an additional medicine is not supported. We suggest saline alone be used for hydrodissection.

Measurement of transurethral bladder neck displacement during tension-free vaginal tape procedure

The rigid catheter guide is used during the tension-free vaginal tape (TVT) procedure to direct the bladder neck away from the retropubic passage of the sling arm. Our aim was to measure, using transperineal ultrasound, the amount of bladder neck displacement by the rigid catheter guide during TVT placement. This is a prospective cohort of 28 patients undergoing the TVT procedure, with or without concomitant pelvic organ prolapse repair. Spearman's correlation was used to analyze the bladder neck displacement from the midline. The median right-sided bladder neck displacement distance was 1.4 cm (0.6-2.0), and the median left-sided bladder neck displacement distance was 1.4 cm (0.8-2.0). The overall perforation rate was 14% (4/28). Bladder neck displacement with the Mandarin guide results in ~1.4 cm of lateral movement.

Hemorrhagic Complication During Placement of Tension-Free Vaginal Tape

A 66-year-old para III with a 20-year history of stress urinary incontinence underwent placement of tension-free vaginal tape. Intraoperative arterial bleeding occurred. An expanding hematoma was palpated postoperatively. Interventional radiology performed a pelvic arteriogram with selective bilateral internal iliac arteriograms, a supraselective anterior division and obturator arteriogram, a left external iliac arteriogram, coil embolization of a branch of the left obturator artery, and gel foam embolization of the anterior division of the left internal iliac artery.

Does Body Mass Index Impact Passing Voiding Trial After Midurethral Sling Procedures for Stress Urinary Incontinence?

: To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI). : The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis. : Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m or 53.5 (12.3) years and 29.8 (5.7) kg/m, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m. : Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.

Does Tension-Free Vaginal Tape Placement at the Time of Total Prolift Colpopexy Affect Distal Anterior Vaginal Support?

: Pelvic organ prolapse (POP) and stress urinary incontinence often require concomitant procedures to treat both conditions. The purpose of this study was to determine whether tension-free vaginal tape (TVT) at the time of total Prolift colpopexy (TPC) affected distal anterior vaginal wall support. : This was a retrospective cohort study of women that had TPC (n = 62) between January 2005 and December 2007. All patients had no uterus and underwent TPC with mesh placement in the anterior and posterior vaginal compartments. A concomitant TVT was placed only in those who had a preoperative diagnosis of urodynamic stress urinary incontinence with prolapse reduction. Patients were subdivided into those with (n = 26) and without TVT (n = 36). Data were compared between groups using Student t, Wilcoxon rank sum, and Fisher exact tests (P ≤ 0.05). : There were no significant differences between groups for all preoperative variables. Patients were observed for 6 to 12 months after TPC. Postoperatively, those with and without TVT had similar anterior POP quantification measurements (points Aa and Ba; P > 0.05), although the group with TVT had significantly more patients with anterior stage 2 and 3 recurrences (23%) when compared with the group without TVT (5%, P = 0.04). : Tension-free vaginal tape does not provide additional distal anterior vaginal wall support for patients undergoing TPC.

TVT or TVT-O Procedure in the Management of Recurrent Urinary Stress Incontinence after Previous Failed Midurethral Tape

Study Objective: Data about the placement of tension-free vaginal tape (TVT) or inside-out trans-obturator TVT-O in the management of recurrent urinary stress incontinence after previous failed midurethral sling procedure (TVT or TVT-O) are missing. The objective of the current study : assessment of the efficacy of the TVT or TVT-O procedure in the management of patients with recurrent urinary stress incontinence after failed previous TVT or TVT-O procedure.

The effect of tension-free vaginal tape placement on distal anterior vaginal wall support at the time of laparoscopic sacral colpoperineopexy

The occurrence of stress urinary incontinence and pelvic organ prolapse can often coexist resulting in the need for concomitant surgical procedures to treat both conditions. The purpose of this study was to determine if tension-free vaginal tape (TVT) at the time of laparoscopic sacral colpoperineopexy (LSCP) had an effect on distal anterior vaginal wall support. This was a retrospective cohort study of patients that had LSCP between January 2005 and December 2007 (n = 121). These patients were divided according to those with (n = 63) and without TVT (n = 58) at the time of LSCP. Pre- and postoperative information was compared between groups using Student's t tests, ANCOVA, and Fisher's exact tests (P ≤ 0.05). Preoperatively, there were no significant differences between groups for all demographic and anatomic variables (P > 0.05). Patients were followed-up until 12 months after surgery. Patients with and without TVT had similar postoperative anterior vaginal wall measurements (points Aa and Ba) and stage of prolapse (P > 0.05). There were also no differences between groups with regard to recurrent prolapse symptoms or surgical satisfaction (P > 0.05). Tension-free vaginal tape at the time of LSCP did not improve postoperative distal anterior vaginal support.

Small bowel perforation in a hernia sac after TVT placement at the time of colpocleisis

Tension-free vaginal tape (TVT) is commonly considered as the first line of treatment for stress urinary incontinence (SUI) with demonstrated efficacy and limited complications. An 82-year-old woman with complete uterine procidentia and SUI underwent a Le Forte colpocleisis, TVT, posterior repair, and cystoscopy. A 4-cm bulge was noted over the site of the left TVT incision on postoperative day 1. On postoperative day 3, she developed bilious vomiting with slight abdominal distention. Computed tomography scan showed a strangulated left inguinal hernia. An immediate exploratory laparotomy noted an inguinal hernia displaced medially with loops of small bowel in the hernia sac. Although properly positioned, one loop of bowel was perforated by the sling mesh. A small bowel resection was performed and the mesh trimmed below the resection on involved side. At 2 months postoperative visit, the patient was asymptomatic, denied stress or urge incontinence. Vaginal examination noted well-supported vaginal walls.

Tension-free vaginal tape bowel perforation

A 73-year-old para 3 white female with posthysterectomy pelvic organ prolapse and stress urinary incontinence underwent pelvic reconstructive surgery and placement of tension-free vaginal tape. On postoperative day 4, she underwent exploratory laparotomy for small bowel obstruction. She was found to have an injury to the small bowel secondary to a through-and-through perforation by tension-free vaginal tape. The entire tape was removed. Partial small bowel resection and primary anastomosis were performed. Her subsequent recovery was uneventful.

FloSeal for Treatment of Retropubic Bleeding During Placement of Tension-Free Vaginal Tape

In Brief Background: Bleeding complications during tension-free vaginal tape placement, although rare, are unpredictable and call for urgent treatment to prevent sequelae such as hematoma or need for blood transfusion. Case: We describe 2 cases of retropubic bleeding that were immediately controlled with FloSeal hemostatic matrix. Conclusion: FloSeal should be considered for treatment of retropubic bleeding not controlled with conventional methods such as application of direct pressure. We describe 2 cases of persistent, brisk retropubic bleeding controlled with FloSeal hemostatic matrix.