Routine Intraoperative Cystoscopy Research Articles

Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis.

To calculate the rates of urinary tract injury detected during and after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy and determine if it helps in reducing injuries detected postoperatively. We conducted a literature search for urinary tract injuries at benign gynecologic surgery in PubMed, EMBASE, ClinicalTrials.gov, and Web of Science from January 2004 to August 2014. We combined our results with a database from a previously published systematic review to include earlier studies. A total of 79 studies met our inclusion criteria. Excluded were letters to the editor, studies involving only selective cystoscopy in higher risk patients, case reports, and reports that included injuries resulting from obstetric or oncologic procedures. Data from each report were classified according to type of surgery into vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, other (nonrobotic) gynecologic and urogynecologic surgery, robotic hysterectomy, and other robotic gynecologic and urogynecologic surgery. We determined the ureteric and bladder injury rates for each surgery type from studies in which routine intraoperative cystoscopy was performed and separately from studies in which it was not performed. Intraoperatively detected rates of ureteric and bladder injury were markedly higher with routine intraoperative cystoscopy. We obtained an adjusted ureteric injury rate of 0.3% and a bladder injury rate of 0.8%. The estimated postoperative ureteric injury detection rates per 1,000 surgeries were 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. Postoperative bladder injury detection rates per 1,000 surgeries were 0.8 without routine cystoscopy and 1.0 with routine cystoscopy. Although routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries, this systematic review of 79 mostly retrospective studies shows that it does not appear to have much effect on the postoperative injury detection rate.

Vesico-cutaneous fistula: unusual complication after transobturator mid-urethral sling

The transobturator tape (TOT) procedure was described in 2001 as the safest sling technique for the treatment of stress urinary incontinence (SUI). Although routine intraoperative cystoscopy to detect bladder and urethra injuries after the TOT procedure is not usually advocated, when such perforations do occur, there is potential for further patient morbidity. We present a case report of a vesico-cutaneous fistula detected after placement of a TOT sling in a 44-year old woman, 3 months postoperatively. Cystoscopic evaluation after mid-urethral sling procedures, especially in high-risk situations such as patients with cystocele, previous pelvic floor surgery or during the learning curve of the procedure, may avoid such complications associated with unrecognized lower urinary tract injuries.

Evaluation of the outcomes of laparoscopic hysterectomy for normal and enlarged uterus (>280 g)

The aim of this study was to evaluate intraoperative and postoperative outcomes of laparoscopic hysterectomy (LH) with routine intraoperative cystoscopy (CYS) for enlarged uterus (>280g). The patients, who underwent LH procedure in the Department of Obstetrics and Gynecology in Düzce University Faculty of Medicine between July 2012 and July 2013, were included in this study. Perioperative outcomes were compared between patients with and without enlarged uterus. Uterus weight of the operated patients ranges between 38 and 700g. Mean uterus weight was 196.40±142.32g. Although we found longer operation time (148.75±32.37 vs. 128.28±27.58) and higher delta hemoglobin (2.98±3.09 vs. 1.61±1.29) in patients with enlarged uterus undergoing LH, these findings were not statistically significant (p=0.077 and 0.058). No significant difference was found between the two groups in terms of need for insertion of pelvic drainage (p=0.664), duration of bladder catheterization (p=0.673), time of first postoperative flatus (p=0.509) and the duration of hospitalization (p=0.844). None of the patients had postoperative fever. The two groups were not significantly different in terms of postoperative body temperature (p=0.736). In normal uterus group, 1 patient developed ureterovaginal fistula and 1 patient required re-operation. No major complication was observed in large uterus group. In our study, we compared the outcomes of LH in patients with large uterus measuring up to 700g. and patients with normal uterus, and we achieved successful results by making minor changes in the operation technique and performing diagnostic CYS at the end of the operation.

Risk Factors for Trocar Injury to the Bladder During Mid Urethral Sling Procedures

We determined the incidence of and risk factors for bladder injury during mid urethral sling procedures for stress urinary incontinence. At our institution 1,136 consecutive women underwent a mid urethral sling procedure (retropubic in 874 and transobturator in 262) and routine intraoperative cystoscopy between 1999 and 2007, and were followed to determine the clinical outcome. Statistical analysis was performed using the chi-square and independent t tests, and ANOVA to compare patients with and without bladder perforation by baseline characteristics and major risk factors. A total of 45 variables were included in analysis. Multivariate analysis to predict events was done with logistic regression models with stepwise forward selection. Bladder injury was noted in 34 patients (3%) and all except 1 were during a retropubic sling procedure (p <0.0001). Of the perforations 32 (94%) were associated with an inexperienced surgeon (p <0.0001). Multivariate analysis revealed that rectocele (OR 6.2), local anesthesia (OR 5.9), body mass index less than 30 kg/m(2) (OR 5.6), previous Cesarean section (OR 3.7) and previous colposuspension (OR 3.2) were significant independent risk factors for perforation. Urethral injury was detected intraoperatively in 2 women (0.2%) with a retropubic sling. Our results indicate that previous Cesarean section, colposuspension, body mass index less than 30 kg/m(2), rectocele and local anesthesia are independent risk factors for bladder perforation during mid urethral sling procedures. This occurs mainly during a retropubic sling procedure and when the surgeon is inexperienced.

Indigo Carmin Test Visualized by Cystoscopy to Identify Ureteral Indemnity during Hysterectomy with McCall Culdoplasty

Study Objective: To evaluate the incidence of ureteral obstruction due to vaginal hysterectomy (VH) or laparoscopic attended vaginal hysterectomy (LAVH) with McCall´s culdoplasty. To determine the effectiveness of indigo carmine test observe by routine intraoperative cystoscopy to identify the ureteral indemnity.

Rates of Urinary Tract Injury From Gynecologic Surgery and the Role of Intraoperative Cystoscopy

To estimate the rates of urinary tract injury after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy at benign gynecologic surgery. We conducted a systematic MEDLINE search for urinary tract injuries at gynecologic surgery for the period from November 1998 to May 2004 and combined this with a previous systematic review performed in the same fashion for the period from January 1966 to October 1998. There were 47 studies that fit our inclusion criteria: 29 that did not use routine intraoperative cystoscopy, 17 that used routine intraoperative cystoscopy, and 1 that reported the frequency of urinary tract injury separately, with and without routine intraoperative cystoscopy. We determined the crude and fitted ureteric and bladder injury rates for each surgery type from the studies where routine intraoperative cystoscopy was not performed and then from the studies where routine intraoperative cystoscopy was performed. From studies without routine cystoscopy, combined ureter and bladder injury rates varied according to the complexity of the surgery, ranging from less than 1 injury per 1000 for subtotal hysterectomy with or without bilateral salpingo-oophorectomy to as many as 13 injuries per 1000 surgeries for laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy and for other gynecologic and urogynecologic surgeries. Injury rates were higher when routine intraoperative cystoscopy was used, but the confidence intervals were wider. The reasons for higher injury detection rates when routine cystoscopy was performed are unclear. Further study is needed to identify the scenarios where routine cystoscopy is warranted after major gynecologic surgery.

True occult bladder perforation during placement of tension-free vaginal tape

Bladder perforation is one of the most common complications of the trans-vaginal tape (TVT) procedure, and is generally identified on routine intra-operative cystoscopy. We present a case of occult bladder perforation occurring during the TVT procedure that could not be identified by cystoscopy. A 57-year-old woman underwent TVT placement for treatment of stress urinary incontinence. A bladder perforation, suspected because of clear fluid at one of the abdominal incision sites, could not be identified with cystoscopy, but was confirmed with bladder installation of sterile infant formula. The tape was removed and the bladder was drained for 48 h. The patient's recovery was uneventful and she subsequently underwent TVT placement without complication. Cystoscopy alone may be inadequate for identification of some bladder perforations during the TVT procedure. Awareness of alternative methods of identification is essential.

Bladder injury during transobturator sling

The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure.

Open Burch urethropexy has a low rate of perioperative complications

Objective: Our purpose was to report perioperative complication rates with open Burch urethropexy in a tertiary care teaching center. Study Design: One hundred fifty-one consecutive hospital and clinic charts of women who underwent Burch urethropexy for genuine stress incontinence between January 1995 and April 2000 were reviewed. Statistical analysis included the χ2 test of association for nominal data and the Mann-Whitney test for comparison of population medians. Results: All women had urodynamically proved genuine stress incontinence and 34% had detrusor instability. Most women (81%) had concomitant surgery for pelvic organ prolapse. Sixty-three percent had prior pelvic surgery with 32% having had a urethropexy, needle suspension, or anterior colporrhaphy. Perioperative complications were uncommon. The rate of lower urinary tract injury from Burch urethropexy was <1%. Two cystotomies (1.3%) were associated with surgery for prolapse, and one Burch suture (0.7%) was noted in the bladder on routine intraoperative cystoscopy. One woman (0.7%) received a single unit of blood after surgery, whereas two women had postoperative ileus. Incisional complications were most common (3%) with five cases of cellulitis and one incisional separation. One woman has prolonged voiding dysfunction and continues to perform intermittent self-catheterization 3 years after surgery. Eight percent of women had de novo detrusor instability. No women had perioperative deep venous thromboses, pulmonary emboli, adverse drug reactions, myocardial infarctions, or peripheral nerve injuries. Twenty-nine women (19%) had Burch retropubic urethropexy without concomitant surgery. There were no lower urinary tract injuries, prolonged catheterizations, or development of de novo detrusor instability in this group. The only perioperative complication was a single case of incisional cellulitis (3%). Conclusion: Open Burch urethropexy has a low rate of perioperative complications. The minimal morbidity of open Burch urethropexy in a teaching setting makes it the preferred teaching technique for this procedure. (Am J Obstet Gynecol 2002;187:107-10.)

The role of intraoperative cystoscopy in prolapse and incontinence surgery

Objective: Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. Study Design: This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the χ2 test. Results: Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy. Conclusion: Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury. (Am J Obstet Gynecol 2001;185:1368-73.)

Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy

Objective: To evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy in terms of cost per ureteral injury identified and treated. Methods: Using a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystoscopy at the time of abdominal hysterectomy. A similar model was constructed for vaginal and laparoscopically assisted vaginal hysterectomy to account for the cost of conversion to laparotomy. Cost estimates were based on estimated costs of Duke University Medical Center and from average Medicare reimbursements for similar Diagnostic Related Groups from the Health Care Financing Administration. The incidence of ureteral injury was obtained from a review of the literature. Sensitivity analyses were performed for the following variables: ureteral injury rate, silent ureteral injury rate, cost of cystoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%. Results: Routine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2%, the marginal increase in the cost of routine intraoperative cystoscopy was $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, with a cost savings of $2200 per ureteral injury identified intraoperatively. At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a marginally increased cost of $83 per hysterectomy, with an incremental cost-effectiveness of $16,600 spent per ureteral injury identified. The model constructed for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy yielded a threshold ureteral injury rate of 2%, above which routine cystoscopy was cost-saving. In both models, the incidence of ureteral injury and the cost of readmission were the two variables with the greatest influence on cost-effectiveness. Conclusion: The cost-effectiveness of routine intraoperative cystoscopy depends on the rate of ureteral injury independent of the route of hysterectomy. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective.

Cost-Effectiveness of Universal Cystoscopy to Identify Ureteral Injury at Hysterectomy

In Brief Objective To evaluate the cost-effectiveness of routine cystoscopy at the time of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy in terms of cost per ureteral injury identified and treated. Methods Using a hospital-based perspective, a decision-analysis model was constructed to estimate the outcomes and costs of cystoscopy or no cystoscopy at the time of abdominal hysterectomy. A similar model was constructed for vaginal and laparoscopically assisted vaginal hysterectomy to account for the cost of conversion to laparotomy. Cost estimates were based on estimated costs of Duke University Medical Center and from average Medicare reimbursements for similar Diagnostic Related Groups from the Health Care Financing Administration. The incidence of ureteral injury was obtained from a review of the literature. Sensitivity analyses were performed for the following variables: ureteral injury rate, silent ureteral injury rate, cost of cystoscopy, and cost of therapeutic interventions. We assumed a silent renal death rate of 0%. Results Routine cystoscopy at abdominal hysterectomy was cost-saving above a threshold ureteral injury rate of 1.5%. At a ureteral injury rate of 0.2%, the marginal increase in the cost of routine intraoperative cystoscopy was $108 per abdominal hysterectomy, with an associated cost of $54,000 per ureteral injury identified. In comparison, at a ureteral injury rate of 2%, routine cystoscopy gave a marginal cost savings of $44 per hysterectomy, with a cost savings of $2200 per ureteral injury identified intraoperatively. At the baseline ureteral injury rate of 0.5%, routine cystoscopy had a marginally increased cost of $83 per hysterectomy, with an incremental cost-effectiveness of $16,600 spent per ureteral injury identified. The model constructed for vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy yielded a threshold ureteral injury rate of 2%, above which routine cystoscopy was cost-saving. In both models, the incidence of ureteral injury and the cost of readmission were the two variables with the greatest influence on cost-effectiveness. Conclusion The cost-effectiveness of routine intraoperative cystoscopy depends on the rate of ureteral injury independent of the route of hysterectomy. If that rate exceeds 1.5% for abdominal hysterectomy and 2% for vaginal or laparoscopically assisted vaginal hysterectomy, then routine cystoscopy is cost-effective. Routine cystoscopy at hysterectomy is cost-saving if the rate of ureteral injury is above 1.5% for abdominal and 2% for vaginal and laparoscopic cases.

Credentialing residents for intraoperative cystoscopy

Objective: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. Methods: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. Results: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. Conclusion: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014–7.)

Intraoperative Cystoscopy in Conjunction With Anti-Incontinence Surgery

The authors investigated the frequency of bladder and ureteral injuries in antiincontinence surgery as detected by routine intraoperative cystoscopy. A review of medical records from 1995 to 1998 identified 347 women who underwent antiincontinence surgery with intraoperative cystotomy. Charts were reviewed, and pertinent data were recorded for analysis. Intraoperative cystoscopy was started after the antiincontinence procedure. After administration of intravenous indigo carmine, the bladder was examined transurethrally with an 70-degree cystoscope or suprapubically through a cystotomy in the dome using a 30-degree cystoscope. Both ureteral orifices were checked for free-flowing indigo carmine–stained urine, and the bladder was examined for intravesical injuries. The 347 patients underwent more than 1000 procedures, with nearly all of the patients having more than one procedure performed. Nine injuries were detected in the 347 cases. Four of 48 women undergoing a laparoscopic Burch procedure sustained a bladder injury that was recognized before cystoscopy was performed. The procedure was converted to laparotomy and the cystotomy repaired. During cystoscopy, four instances of sutures in the bladder were detected. All of them occurred during 161 pubovaginal sling procedures, yielding an injury rate of 2.5 percent with a 95% confidence interval of 0.7 to 6.2. They were removed and replaced, and the patients experienced a normal recovery. In one woman, who was undergoing an open Burch procedure, intravesical sutures from a prior needle urethropexy were detected by cystoscopy. They were removed by cystotomy. In all, five injuries were detected during cystoscopy, a rate of 1.5 percent with a 95% confidence interval of 0.5 to 3.4. No new unrecognized injuries during Burch procedures (48 laparoscopic and 138 open) were detected during cystoscopy. In two women polypoid lesions in the bladder mucosa were discovered, and biopsy samples were obtained. No ureteral injuries occurred in this series. One woman had an apparent transient ureteral spasm that impeded the flow of urine from her left ureter until it was opened by passage of a 25-cm stent. There was no apparent suture injury in this patient. Statistical analyses identified no variables associated with preoperative or intraoperative injury. Obstet Gynecol 2000;95:794–796

Intraoperative cystoscopy in conjunction with anti-incontinence surgery

Objective: To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery. Methods: We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables. Results: We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0.5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury. Conclusion: The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy.

Intraoperative Cystoscopy in Conjunction With Anti-Incontinence Surgery

In Brief Objective To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery. Methods We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables. Results We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0.5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury. Conclusion The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy. Injury to the urinary tract during anti-incontinence surgery is infrequent.

The value of intra-operative cystoscopy at the time of laparoscopic hysterectomy.

The aim of this study was to determine the usefulness of routine intra-operative cystoscopy in documenting ureteral injury during total laparoscopic hysterectomy with vault suspension and to document the incidence of this complication in a large series. The charts of 118 patients who underwent laparoscopic hysterectomy with vault suspension from January 1992 to January 1998 were retrospectively reviewed. The patients underwent intra-operative cystoscopic evaluation to verify ureteral permeability and bladder integrity. Intra-operative ureteral obstruction occurred in four patients (3.4%). All complications were immediately fixed and there were no postoperative ureteral problems. No late ureteral complications were observed. Intra-operative cystoscopy allows for early recognition and treatment of obstructive ureteral injuries and may reduce the rate of late postoperative complications during advanced laparoscopic procedures.

Suture injury to the urinary tract in urethral suspension procedures for stress incontinence.

The case histories of women attending the Urogynecology Department at the Royal Women's Hospital and Mercy Hospital for Women were reviewed between 1986 and 1998 to determine the incidence and postoperative morbidity caused by suture injury to the urinary tract following urethral suspension surgery for stress incontinence. In our department 1103 Burch colposuspensions and 61 Stamey urethral suspensions have been performed. Intraoperative cystourethroscopy was performed routinely for the early detection and treatment of urinary tract injury. Intravesical sutures were found by routine intraoperative cystoscopy in 1 Stamey suspension, 1 open Burch colposuspension and 3 laparoscopic Burch colposuspensions. Ureteric suture ligation was diagnosed in 2 women intraoperatively and 1 women postoperatively after laparoscopic Burch colposuspension. Two women presented with late complications from intravesical sutures following open Burch colposuspension. A further 7 women referred with urinary symptoms were found to have intravesical sutures, 2 following Burch colposuspension, 4 following Stamey urethral suspension and 1 following the Marshall-Marchetti-Kranz procedure. Seven of the 9 women diagnosed with intravesical sutures presented with bladder or pelvic pain, frequency or urinary tract infection. Two women had recurrent stress incontinence and were found to have a intravesical suture on routine cystoscopy at the time of stress incontinence surgery. Suture removal, with any accompanying calculus, was achieved cystoscopically with almost immediate resolution of symptoms without loss of urinary control in all cases. Non-absorbable intravesical sutures occurring as a result of suture misplacement or erosion is an infrequent but important complication of stress incontinence surgery, but should be suspected if pain and irritative bladder symptoms or recurrent urinary infection occur postoperatively. Cystourethroscopy performed intra-operatively or postoperatively is essential for early diagnosis and treatment.