INTRODUCTION: The transobturator approach was first described by Delorme in 2001. It has become the preferred approach for suburethral sling placement in many centers due to its efficacy and low morbidity. Nevertheless, complications have been associated with it.
METHODS: The authors describe management of a female subject with intractable groin pain after the insertion of an artisanal transobturator sling. The right side of the sling was removed.
RESULTS: The patient described significant but incomplete pain improvement at the time of hospital discharge. After one week, she had no pain but moderate stress urinary incontinence recurred.
CONCLUSION: The present case illustrates that a partial removal is not indicated for complete treatment. Time-related intractable groin pain may completely subside after sling tape removal. However, possible recurrence of urinary incontinence following intervention must be reinforced during patient counseling.
KEYWORDS: Synthetic slings; Transobturator; Groin pain
CORRESPONDENCE: Paulo Palma, MD, PhD, Division of Urology, Department of Surgery, Rua Jose Pugliesi Filho 265, Campinas, Sao Paulo, Brazil 13085-415 ()
INTRODUCTION
The transobturator approach was first described by Delorme in 2001 [1]. It has become the preferred approach for suburethral sling placement in many centers due to its efficacy and low morbidity. Nevertheless, complications such as leg pain in the inner part of the thigh have been associated with it. This pain is due to entrapment of nerve fibers of the obturator nerve and its branches and is more frequent with the inside-out approach [2].
The authors of the present report describe management of a female subject with intractable groin pain after the insertion of an artisanal transobturator sling.
CASE REPORT
History
A 54-year-old female patient was referred to the authors’ clinic after undergoing an artisanal inside-out polypropylene mesh transobturator suburethral sling placement for treatment of urodynamic stress urinary incontinence. The procedure was uneventful according to the referring physician and she was discharged on the day after surgery, despite complaints of groin pain on the right side.
The patient was put on a nonsteroidal anti-inflammatory trial and bed rest for 1 week. She was referred to the authors’ hospital for evaluation because no pain relief was achieved. A thorough clinical workup was made including physical examination, computed tomography scan, and laboratory tests to rule out infection or groin abscess formation. No obvious cause was identified. Therefore, initial treatment was carried out with 3 sessions of local injections of 2% lidocaine and steroids.
The patient denied pain improvement following the procedure and was unable to work or perform routine daily activities. Therefore, she accepted the proposal of surgical removal of the mesh.
Procedure
The procedure was done under spinal anesthesia. Two incisions were made. One was longitudinal, 2 cm below the urinary meatus; the other was 2 cm parallel to the inguinofemoral fold, at the level of the clitoris (Figure 1).
The suburethral tape was indentified and dissected out from the midline toward the right obturator foramen. At groin level, the authors were able to identify the tape anchored by 2 stitches placed at the tip of the mesh onto the abductor muscle fascia (Figure 2).
With careful dissection under direct vision, the authors were able to completely remove half of the suburethral tape on the right side (Figure 3). The skin and vaginal wall were closed in the usual manner and a vaginal pack was left overnight.
Outcome
The patient described significant but incomplete pain improvement at the time of hospital discharge. After one week, she presented with absolutely no pain, but moderate stress urinary incontinence recurred. She refused any further treatment for her incontinence.
DISCUSSION
Leg pain is one of the most frequent complications of transobturator slings. This particular case presented two educational features. First, the outside-in approach is prone to produce leg pain because the needle enters the pelvis laterally. This approach is closer to the obturator nerve bundle [3] which may be trapped by the fibrosis around the mesh, notably the ones that are designed for hernia repair. This type of "artisanal" mesh produces a more intense and long-lasting inflammatory reaction around it [4]. Second, anchoring stitches were used at the tape ends for initial sling placement. This may also contribute to increasing fibrosis and pain due to obturator neuropathy.
In fact, in a recent prospective study comparing tension-free vaginal tape (TVT) versus tension-free obturator tape (TVT-O), leg pain was found in 0% and 26.4% of the patients in each group, respectively. There were similar short-term success rates, suggesting that the transobturator route should not be recommended [5]. There still is some controversy regarding this issue, because another prospective study comparing Sparc&TM; (retropubic) versus Monarc&TM; (transobturator) slings showed lower pain incidence in the outside-in (TOT) group [6].
Another case reported in the literature showed that a partial removal of the tape was not sufficient to improve the pain [7]. It was necessary to explore the transoburator space in order to completely remove the tape and alleviate the pain.
Histological changes may also be responsible for leg pain development. The authors of the present report previously described histological changes in an animal study comparing the polypropylene sling with nonspecific polypropylene mesh for hernia repair. They demonstrated a more intense and long-lasting inflammatory response when meshes for hernia repair were used [4].
CONCLUSION
The present case illustrates that time-related intractable groin pain may completely subside after sling tape removal and should be offered as a reasonable alternative treatment for patients. Partial removal resulted in loss of pain for this patient, but resulted in moderate stress urinary incontinence. Possible recurrence of urinary incontinence following intervention must be reinforced during patient counseling.
Another consideration should be made about the pathway used in the procedure. Leg pain complication can be avoided by the inside-out approach.
REFERENCES
- Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women [in French]. Prog Urol. 2001;11(6):1306-1313. PubMed
- Deng YD, Rutman M, Raz S, Rodriguez L. Presentation and management of major complications of midurethral slings: are complications under-reported? Neurourol Urody. 2007;26(1):46-52. PubMed
- Achtari C, McKenzie BJ, Hiscock R, et al. Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(4):330-334. PubMed
- Maciel LC, Glina S, Palma PC, Nascimento LF, Neto NR Jr. Histopathological alterations of the vas deferens in rats exposed to polypropylene mesh. BJU Int. 2007;100(1):187-190 PubMed
- Teo R, Moran P, Mayne C, Tincello D. Randomized trial of TVT and TVT-O for the treatment of urodynamic stress urinary incontinence in women [ICS abstract]. Neurourol Urodyn. 2008;27:572-573.
- Freeman R, Holmes D, Smith P, et al. Is transobturator tape (TOT) as effective as tension-free vaginal tape (TVT) in the treatment of women with urodymamic stress urinary incontinence? Results of a multicentric RTC [ICS abstract]. Neurourol Urodyn. 2008;27:573-574.
- Wolter C, Starkman J, Scarpero H, Dmochowski R. Removal of transobturator midurethral sling for refractory thigh pain. Urology. 2007;72(2):461.e1-461.e3. PubMed
To Cite this Article: Palma P, Riccetto C, Herrmann V, Miyaoka R, Dalphorno FF. Artisanal transobturator sling removal for intractable groin pain. UIJ. 2009 Jun;2(3). doi:10.3834/uij.1944-5784.2009.06.03