Retropubic Midurethral Sling Placement Research Articles

Risk Factors for Bladder Perforation at the Time of Retropubic Midurethral Sling Placement.

There is conflicting evidence regarding predictive factors for bladder perforation during retropubic midurethral sling (R-MUS) placement and lack of evidence to support adoption of techniques to minimize such injury. The aims of the study were to describe the incidence of and factors associated with bladder perforation during R-MUS placement and to explore whether retropubic hydrodissection decreases the likelihood of perforation. This is a case-control study of women undergoing R-MUS placement from 2007 to 2017. Cases were identified by review of the operative reports for evidence of bladder perforation. Patients without bladder perforation were defined as controls and were matched to cases in a 3:1 ratio by surgeon, sling type, and surgery date. A total of 1,187 patients underwent R-MUS placement. The incidence of bladder perforation was 8% (n = 92 patients); 276 controls were matched accordingly (N = 368). Patients with bladder perforations were more likely to have a body mass index (BMI) less than 30 (P = 0.004) and to have a diagnosis of endometriosis (P = 0.02). They were also more likely to have had previous hysterectomy (P = 0.03) and urethral bulking (P = 0.01). On logistic regression, bladder perforation remained associated with a BMI less than 30 (adjusted odds ratio, 2.22 [95% confidence interval, 1.30-3.80]) and endometriosis (adjusted odds ratio 2.90 [95% confidence interval, 1.15-7.01]). Retropubic hydrodissection was performed in 62% of the patients and was not associated with a lower risk of perforation (P = 0.86). The incidence of bladder perforation was 8%. The risk of this complication is higher in patients with a BMI less than 30 and/or endometriosis. Retropubic hydrodissection may not decrease the likelihood of this event.

Case report of sigmoid colon perforation and colocutaneous fistula due to retropubic midurethral sling placement for stress urinary incontinence

BackgroundSigmoid bowel perforation is a very rare and serious complication of the retropubic tension-free vaginal tape (TVT) procedure for female stress urinary incontinence. The complication can be avoided with the use of the correct manipulation technique.Case presentationA 75-year-old female patient underwent a retropubic TVT procedure in the local hospital for the treatment of stress urinary incontinence. The procedure was smooth. Two weeks after surgery, the patient began to complain of fever and bloody, purulent discharge from the left suprapubic skin wound. During a 4-month period after surgery, she was admitted to the local hospital 4 times for similar infection symptoms. The infections were temporarily controlled with antibiotic administration. The reason for the refractory infection of the left suprapubic skin wound was not identified until a foreign TVT mesh was found in the sigmoid colon via a colonoscopy. We diagnosed that the TVT mesh caused a sigmoid colon perforation that led to colocutaneous fistula. An exploratory laparotomy revealed that the TVT tape perforated into and out of the sigmoid colon. An 8-cm long left part of mesh was removed. Two ruptures of sigmoid colon were mended without the need for bowel resection. At the 4-years follow-up after laparotomy, the patient was doing well and still continent.ConclusionsUrologists and gynecologists should be aware of the possibility of colon bowel injury in SUI patients with prior sling surgeries. Patient having recurrent suprapubic cutaneous infection may have high degree of suspicion of colon injury after TVT sling. The passage of the retropubic space procedure should be slow and always along the pubic bone according to the anatomy.

41: Sling plication for persistent stress urinary incontinence after midurethral sling

To demonstrate the sling plication technique, a treatment option for failed midurethral sling. Persistent or recurrent stress urinary incontinence after midurethral sling placement is a relatively common problem. Treatment options include placement of a second midurethral sling, autologous fascia sling, colposuspension, or urethral bulking. Sling plication is an alternative option that offers some advantages over a repeat sling procedure: it can decrease cost and operative time, and it avoids the risk of trocar injury and additional mesh burden. In this video, we demonstrate the sling plication technique on a 74-year-old patient with persistent stress urinary incontinence 5 weeks after retropubic midurethral sling placement. The key steps are as follows: suburethral incision and sharp dissection to identify the sling; mobilization of 4 cm of the sling; plication with two interrupted, horizontal sutures placed 1cm laterally on each side; application of upward pressure while tying the sutures and tensioning the sling; and closure of the vaginal epithelium. Sling plication is an effective, low-risk option to treat persistent stress urinary incontinence after failed midurethral sling procedures.

Surgical Approach to a Retropubic Mid-Urethral Sling After Pelvic Trauma

Video Objective Demonstrate our approach to a patient desiring surgical incontinence treatment following pelvic trauma that significantly distorted the anterior pelvic anatomy. Setting Our patient is a 75-year-old female who presented to our quaternary referral center. She has a past medical/surgical history of mixed urinary incontinence, osteoporosis, and prior surgical repair of pelvic organ prolapse. In April 2018, she suffered a major trauma due to a tree falling on top of her, including 5 pelvic fractures. She subsequently had constant, profuse stress urinary leakage with any activity. CT abdomen/pelvis showed severe displacement of the right superior and inferior pubic rami, distortion of the urinary bladder, mild displacement of the pubic rami on the left, and sacral insufficiency fractures. Serial imaging was obtained and reviewed with orthopedic surgery until there was interval improvement. She then proceeded with surgery. Interventions Our video demonstrates successful retropubic mid-urethral sling placement. The procedure began with a rigid cystourethroscopy to identify the patient's anatomy. At the dome of the bladder, a protrusion from the right superior pubic ramus is seen causing distortion. To avoid this, the targeted suprapubic incision is also adjusted towards the midline. The sling is placed with the trocar aimed in this trajectory. A post-insertion cystourethroscopy with both a rigid and flexible cystoscope was then performed to thoroughly rule out injury. Conclusion Some key learning points from our video are that in a patient with distorted pelvic anatomy, multidisciplinary management is critical and orthopedic surgery should determine stability of the pelvis. A thorough evaluation of anatomy before the procedure should be performed since typical landmarks are unreliable. Care should be taken to individualize the approach and realign the usual target sites to avoid injury. A thorough evaluation for injury after the procedure should also be performed.

Liposomal Bupivacaine Versus Bupivacaine Hydrochloride with Lidocaine during Midurethral Sling Placement: A Randomized Controlled Trial

To study the effects of liposomal bupivacaine (LB) compared with bupivacaine hydrochloride with lidocaine on postoperative day 1 pain scores. A randomized controlled trial (Canadian Task Force classification 1). An academic medical center within the department of female pelvic medicine and reconstructive surgery. Fifty-seven patients undergoing midurethral sling placement by a fellowship-trained urogynecologic surgeon and a fellow in female pelvic medicine and reconstructive surgery. Fifty-seven patients were enrolled to participate in this study. There were 24 patients randomized to receive liposomal bupivacaine and 33 to receive a mixture of bupivacaine and lidocaine during the placement of a retropubic midurethral sling. Patients were given a diary of pain scales and asked to record their level of pain using the provided visual analog scale scored on a 100-mm Likert scale. Patients recorded their pain 4 hours after hospital discharge and on the night of surgery and their most intense pain each day thereafter for 7 days postoperatively. In addition, patients recorded total opioid and nonsteroidal anti-inflammatory drug consumption daily for 1 week postoperatively. Finally, the quality of recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire scores. The median pain score in the experimental group was 20 mm (range, 0-80 mm) versus 30 mm (range, 0-60 mm) in the comparative group (p = .046). The postoperative day 1 QoR-15 scores were significantly lower in the LB group (124 [range, 54-150] vs 144 [range, 68-150], p = .007). There were no significant differences in opioid and nonsteroidal anti-inflammatory drug consumption, the remaining pain scores, or postoperative day 7 QoR-15 scores. The results suggest the use of liposomal bupivacaine during retropubic midurethral sling placement does not provide a clinically significant difference in postoperative day 1 pain scores when compared with immediate-acting bupivacaine hydrochloride and lidocaine.

28: Management of intravesical mesh and incisional pain after midurethral sling placement

The objective of this video is to demonstrate the laparoscopic excision of an intravesical midurethral sling with concurrent removal of the sling arm through a suprapubic skin incision. This video describes the excision of both intravesical midurethral sling and incisional pain temporally related to the same surgical procedure. The patient described is a 48 year old who underwent Lynx retropubic midurethral sling placement at an outside facility. Review of her operative note revealed the fact that there was gross hematuria with bladder drainage after sling placement, however cystoscopy demonstrated no evidence of bladder injury. One week later, she developed a large hematoma and underwent evacuation, with an incision made through her left suprapubic incision. She presented to our practice 10 months later with urgency, frequency, recurrent urinary tract infections, and left sided incisional pain. Physical examination revealed significant tenderness and nodularity along her left suprapubic incision. Cystoscopy demonstrated a 2 cm intravesical portion of the midurethral sling penetrating the left dome of the bladder. The decision was made to proceed with laparoscopic removal of the intravesical mesh and complete removal of the left sided sling arm through a small suprapubic incision. Management of both intravesical midurethral sling and incisional pain is able to be accomplished using a laparoscopic approach with extraction through prior suprapubic incision.

Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial

Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.

Incidence of Bladder Injury During Retropubic Midurethral Sling Placement After Prior Burch Colpopexy.

To elucidate if prior Burch changes the risk of bladder injury or rates of voiding dysfunction and continence in the immediate postoperative period when undergoing retropubic midurethral sling (MUS) placement. In this retrospective case control, charts were selected by Current Procedural Terminology codes for MUS placement. Women undergoing retropubic MUS placement with history of Burch urethropexy were considered. For every case, 2 age-matched and parity-matched controls without prior Burch were selected. In total, 538 charts were reviewed from 2010 to 2014. Twenty cases were found. There was a difference (P = 0.023) in trocar penetration of the bladder. Twenty-five percent (5/20) of women with prior Burch had a 9-fold (odds ratio [OR], 9.0; 95% confidence interval [CI], 1.0-82) higher chance of bladder penetration compared with women without prior retropubic surgery as calculated with Mantel-Haenszel paired test. Women with prior Burch had more success passing their voiding trials (OR, 7.5; 95% CI, 1.1-49.2). At 6 weeks, there was no difference in voiding dysfunction. Cure of stress incontinence at 6 weeks occurred more in controls than cases (P = 0.044) with match pairs manifesting an OR of 0.20 and 95% CI of 0.04-1.1. This study shows a significant increase risk of trocar penetration of the bladder during retropubic MUS placement in women with a history of Burch urethropexy. Despite this, MUS placement was successful in all women. Women with prior surgery were much more likely to pass their voiding trials. There was no difference in voiding dysfunction at 6 weeks between the 2 groups. This indicates that though bladder penetration with a trocar is more common in the setting of previous retropubic surgery, it does not impact a woman's short-term intraoperative or postoperative course.

Laparoscopic-assisted Retropubic Midurethral Sling Placement: A Technique to Avoid Major Complications

Study ObjectiveTo describe a technique for the safe placement of retropubic midurethral slings in patients undergoing concomitant laparoscopic surgery in order to avoid major complications associated with this procedure such as bladder perforation and retropubic hematomas. DesignStep-by-step video demonstration of the technique. SettingA university tertiary care hospital. PatientsPatients with an indication for retropubic midurethral sling placement because of recurrent stress urinary incontinence, intrinsic sphincter deficiency, or severe pelvic organ prolapse in whom a concomitant laparoscopic surgery has to be performed for other medical conditions. InterventionLaparoscopic opening and dissection of the Retzius space and insertion of the sling under a laparoscopic view of this space. Measurements and Main ResultsThis technique has been mainly used in patients undergoing laparoscopic pelvic organ prolapse repair. No complications have been identified so far, even in high-risk patients such as those with previous Burch colposuspension. ConclusionThis is a simple and reproducible technique for preventing major complications associated with retropubic sling placement in patients undergoing laparoscopic surgery for other reasons. It also permits the immediate detection and even resolution of complications in case any arise. Even high-risk patients may be safely approached.

Safety and Efficacy of Retropubic Mid-urethral Sling Placement in Women Who Void With Valsalva

To compare outcomes after retropubic sling (RPS) in women with and without Valsalva voiding. Women who underwent RPS for stress incontinence from 2010 to 2014 were identified and their baseline characteristics were examined. Valsalva voiding was defined as abdominal straining throughout voiding on preoperative urodynamics. Sub-analysis of those with Valsalva included a subset with detrusor underactivity on urodynamics. Follow-up was at 1, 3, 6, and 12 months. Primary outcomes were rates of subjective success, revisions, complications, and voiding dysfunction. Secondary measures were Urogenital Distress Inventory (UDI-6) score, Incontinence Impact Questionnaire (IIQ-7) score, post-void residual, and pad use. Subjects (n = 141) analyzed included 75 Valsalva voiders (VV) and 66 non-Valsalva voiders. At baseline, there were no differences in age, race, comorbidity, post-void residual, pad use, UDI-6, or capacity. Postoperatively, there were no differences in rates of passing initial void trial, need for clean intermittent catheterization, revisions, complications, or voiding dysfunction. No differences in pad use, UDI-6, or IIQ-7 were seen at 6 or 12 months. Within VV, no differences between patients with and without detrusor underactivity were seen for any primary or secondary outcomes (all P > .05). In patients who void with Valsalva, RPS appears to be safe and effective. Between VV and non-Valsalva voiders, there were no differences in rates of subjective success, revisions, or complications, even in patients with Valsalva voiding without appreciable detrusor contraction.

Clitoral Pain Following Retropubic Midurethral Sling Placement.

IntroductionAlthough uncommon, postprocedural pain with associated sexual dysfunction may be seen in patients after retropubic midurethral sling placement for treatment of stress urinary incontinence.AimsTo describe a report of a woman who developed localized severe, persistent periclitoral pain after placement of a retropubic midurethral sling.MethodsA healthy 41‐year‐old underwent an uncomplicated retropubic midurethral sling procedure. She developed persistent postoperative clitoral pain with worsening associated with arousal, impairing sexual function. Symptoms resolved with time and a course of steroid medication.Main Outcome MeasuresTo report a case of clitoral pain following midurethral sling surgery, and to provide a discussion about clitoral innervation, possible pain etiologies, and management options.ResultsWe report a case of clitoral pain associated with sexual dysfunction and provide a review of clitoral innervation as well as potential mechanisms of nerve injury associated with a retropubic sling procedure.ConclusionClitoral pain symptoms following placement of a retropubic midurethral sling should be evaluated and promptly addressed, given the potential negative impact on the patient's sexual function. Christofferson M, Barnard J, and Montoya TI. Clitoral pain following retropubic midurethral sling placement. Sex Med 2015;3:346–348.

Expectant management of cystotomy at the time of midurethral sling placement: a retrospective case series

Cystotomy is one of the most common complications of retropubic midurethral sling placement. Some centers manage cystotomy with prolonged catheter drainage, and there are few published studies evaluating this practice. The purpose of this study is to review postoperative outcomes of patients who experienced cystotomy at the time of sling placement and did not undergo prolonged catheter drainage. This is a retrospective review of all patients undergoing midurethral sling placement complicated by a cystotomy at the University of Rochester between 2004 and 2009. Outpatient and inpatient records were reviewed and data collected include demographics, intraoperative details, voiding trial results, postoperative complications, and voiding function. Descriptive statistics were performed. Between 2004 and 2009, 30 subjects experienced a cystotomy of the 374 subjects that had a midurethral sling placed, all by a suprapubic approach. There were 25 patients who underwent a voiding trial on the day of surgery and 20 (80 %) were discharged home without prolonged drainage. Five subjects (20 %) had urinary retention and were discharged with an indwelling catheter. All five successfully voided within 4 days of discharge. No subject required subsequent catheterization for any reason and at the 6-week postoperative evaluation all subjects denied voiding dysfunction or irritative bladder symptoms. No subject required additional intervention and postoperative complications were rare. In this study, the majority of subjects experiencing a cystotomy during midurethral sling placement were successfully discharged home the day of surgery without catheter drainage. The results suggest that prolonged catheter drainage after a cystotomy during midurethral sling placement may be unnecessary.

Unrecognized Bladder Perforation Leading to Severe Progressive Cellulitis and Candidal Infection

Retropubic midurethral slings are a minimally invasive surgical procedure used in the treatment of stress urinary incontinence and are typically associated with high cure rates and low complication rates. Bladder perforation is a known intraoperative complication that, if left unrecognized, can have significant morbidity. A 47-year-old underwent a retropubic midurethral sling, anterior colporrhaphy, and cystoscopy. She developed a suprapubic wound cellulitis that progressed to involve the right trunk and flank as well as persistent fever for more than 48 hours despite broad-spectrum antibiotics. Upon return to the operating room, the patient was found to have an unrecognized bladder perforation with mesh in the bladder. Wound culture was remarkable for Candida parapsilosis and Escherichia coli. Unrecognized bladder perforation and nonbacterial causes of infection should be considered in patients with severe progressing cellulitis despite broad-spectrum antibiotic coverage after retropubic midurethral sling placement.

Remote discovery of an asymptomatic bowel perforation by a mid-urethral sling

Bowel perforation is a rare complication of mid-urethral sling procedures and is usually reported shortly after the surgery. We report a remotely discovered asymptomatic bowel injury found at the time of subsequent surgery. The patient with a history of several prior pelvic surgeries underwent an uneventful retropubic mid-urethral sling placement. Five years later, during an abdominal sacrocolpopexy procedure, mesh from the mid-urethral sling was found perforating the wall of the cecum and fixating it to the right pelvic sidewall. Cecal wedge resection was performed to excise the sling mesh. Asymptomatic bowel perforation by mid-urethral sling mesh has not been previously reported. Pelvic and abdominal surgeons should be aware of the possibility of finding this injury in patients with prior sling surgeries.

Worse long‐term surgical outcomes in elderly patients undergoing SPARCTM retropubic midurethral sling placement

• The purpose of our study was to evaluate long-term clinical outcomes following placement of a retropubic mid-urethral sling in patients aged 70 and over and to compare outcomes with those of a younger cohort of patients. • Patients with stress urinary incontinence undergoing retropubic polypropylene sling (SPARC(TM) ) placement were entered into a prospective, institutional review board-approved database. • Patients with at least 12 months follow-up were sent postoperative questionnaires assessing outcomes. Results of these questionnaires were compared for patients aged 70 or older and those younger than 70 years. • A total of 337 patients who underwent SPARC sling placement in an 8-year period were identified. Of these, 290 patients had a minimum of 12 months follow-up, and among these patients, 235 (81%) answered postoperative mailed questionnaires. Average follow-up was 45.2 months. • Thirty-seven patients were 70 or older, and 198 were younger than 70. The older group had significantly lower success (53.1% vs 83.6%) and dry (6.1% vs 35.3%) rates than the younger cohort. • Assessment of preoperative variables determined that the older cohort had significantly more vaginal deliveries and a higher percentage of patients who had undergone either hysterectomy, previous prolapse and/or incontinence surgery. • There was no significant difference in Valsalva leak-point pressure, percentage of patients with intrinsic sphincteric deficiency or type 0 stress urinary incontinence between the two groups. • Experience at our Institution shows that there are clearly lower success rates in older patients undergoing a SPARC sling as compared with a younger cohort of patients. • Parity, hysterectomy and previous pelvic organ prolapse/anti-incontinence surgery may also play a role in the difference in outcomes.