ABSTRACT
We present a case of 2 patients with late bladder erosion and vesical stone formation due to mesh erosion from mid-urethral polypropylene slings and their management. Patients presented 18 and 22 months after surgery with hematuria, recurrent urinary tract infections, and lower urinary tract symptoms. Stone fragmentation was done by pneumatic lithotripsy, and transurethral resection of the mesh was performed using a 26 Fr resectoscope. Postoperative control cystoscopy demonstrated complete healing of bladder mucosa after 3 months. The patients were satisfied with this result, and the patients reported significant improvement of symptoms. The patients remained completely continent at the follow-up period. The endoscopic management of the eroded mesh should be the first choice of bladder erosion therapy. Careful and comprehensive urethrocystoscopy is mandatory during a mid-urethral sling procedure. There is a need for long-term follow-up of patients with mid-urethral slings. We present a case of 2 patients with late bladder erosion and vesical stone formation due to mesh erosion from mid-urethral polypropylene slings and their management. Patients presented 18 and 22 months after surgery with hematuria, recurrent urinary tract infections, and lower urinary tract symptoms. Stone fragmentation was done by pneumatic lithotripsy, and transurethral resection of the mesh was performed using a 26 Fr resectoscope. Postoperative control cystoscopy demonstrated complete healing of bladder mucosa after 3 months. The patients were satisfied with this result, and the patients reported significant improvement of symptoms. The patients remained completely continent at the follow-up period. The endoscopic management of the eroded mesh should be the first choice of bladder erosion therapy. Careful and comprehensive urethrocystoscopy is mandatory during a mid-urethral sling procedure. There is a need for long-term follow-up of patients with mid-urethral slings.
Emrah Okulu, Kemal Ener, Mustafa Aldemir, Onder Kayigil
Submitted March 21, 2013 - Accepted for Publication April 22, 2013
KEYWORDS: Bladder erosion, incontinence surgery, vesical stone
CORRESPONDENCE: Emrah Okulu, M.D., Umit Mh. Meksika Cd. 2463. sk. 4/32, Umitköy, Yenimahalle, Ankara, Turkey ()
CITATION: UroToday Int J. 2013 June;6(3):art 41. http://dx.doi.org/10.3834/uij.1944-5784.2013.06.15
INTRODUCTION
Mid-urethral sling procedures with artificial sling material have become increasingly popular. This popularity is due to the fact that artificial sling material simplifies the operative procedure because the graft is readily available and does not require harvesting from a second operative site. There are several advantages of using synthetic slings: shortened operative time, early postoperative patient recovery, and an unlimited supply of artificial material. This has led to an increase in the number of sling procedures [1].
All synthetic materials provide similar success rates, but none is free of complications. Several factors contribute to the wide range of erosion/extrusion rates, including operative technique, implant size, and the specific properties of the sling material such as small mesh pore size, local ischemia, stiffness involving poor tissue irrigation, elasticity, poor mesh incorporation, subclinical infection, and basic tissue compatibility [1]. The reported incidence of bladder erosion by mid-urethral sling tapes ranges from 0.5 to 24% [2]. Most of the erosion of graft materials may occur relatively late, usually 1 year, postoperatively [2]. In this study, we report 2 patients who had bladder erosion of the prolene mesh at 18 and 22 months. This emphasizes the need for long-term follow-up of these patients.
CASE REPORTS
Case 1
A 67-year-old woman was treated for urinary stress incontinence with the transobturator tape (TOT) procedure at another clinic in 2009. She presented with symptoms of hematuria, dysuria, recurrent urinary tract infections, and pronounced urge symptoms 18 months after surgery. Under repeat therapy with antibiotics, urinalysis showed significant leukocyturia, and microhematuria. She was referred to our clinic. The patient underwent urodynamic tests. All tests were normal. A cystoscopy was done at the time of the TOT procedure. Computerized tomography (CT) showed a bladder stone fixed to left bladder wall (Figure 1). The patient underwent cystoscopy, which demonstrated a stone over the eroded polypropylene mesh material within the bladder wall. This stone was successfully fragmented by pneumatic lithotripsy (Figure 1) and the urethra was not involved with stone formation. During cystoscopy, lateral and anteroposterior cystography was performed on the patient. There were no fistulae (Figure 1). Sufficient heat could only be applied to the mesh when it or part of the resection loop was in contact with bladder tissue, allowing completion of the diathermy circuit during transurethral resection (TUR) using monopolar diathermy and an endoscopic view after TUR of the bladder mucosa (Figure 1). The operative time was 25 minutes. Urethral catheters were removed on the seventh day, postoperatively. After removal of the urethral catheters, the patient remained continent. The patient was discharged on the second postoperative day. Three months later, a control cystoscopy revealed complete healing of the bladder mucosa (Figure 1). The patient was satisfied with this result. She remained completely continent at a follow-up period.
Case 2
A 63 year-old woman underwent a transvaginal tape (TVT) procedure for urinary stress incontinence at another clinic in 2009. She presented with symptoms of dysuria, recurrent urinary tract infections, pronounced urge symptoms, and a feeling of incomplete bladder emptying 22 months after surgery. She was referred to our clinic. A transabdominal ultrasound showed a bladder stone fixed to the right bladder wall. It is not known whether a cystoscopy was done or not at the time of the TVT procedure. Sonography confirmed a post-void residual urine volume of 150 to 200 mL. The patient underwent urodynamic testing. This revealed a bladder capacity of 450 cc, post-void residual volume was 150 cc, and there was no evidence of stress incontinence. The patient underwent cystoscopy, which demonstrated a stone over the eroded polypropylene mesh material within the bladder wall. This stone was successfully fragmented by pneumatic lithotripsy (Figure 2a). The prolene sutures that eroded to the bladder wall were cut with endoscopic scissors (Figure 2b). After removal of prolene sutures and mesh, the patient underwent TUR. The operative time was 32 minutes. After removal of the urethral catheters on the seventh day, postoperatively, the patient remained continent. A control cystoscopy revealed complete healing of the bladder mucosa after three months of resection (Figure 2b). The patient reported significant improvement of symtoms. The patient remained completely continent at a follow-up period.
DISCUSSION
The mid-urethral sling using TVT and TOT has become a popular choice for the treatment of stress urinary incontinence. Bladder erosion is one of the more common complications of the retropubic approach, but it is rarely encountered using the transobturator route. In a meta analysis of complications reported in 1,854 patients, bladder perforation was most common, occurring in 3.5% of retropubic sling insertions and in 0.2% of procedures using the transobturator route [3].
The unrecognized perforation of the bladder during the insertion of a mid-urethral sling results in the development of considerable symptoms and negatively impacts quality of life. The presence of mesh within the bladder may arise either from direct bladder perforation, which is missed at cystoscopy (if done) or from subsequent erosion of a submucosal sling [4]. A thorough clinical examination and cystoscopic evaluation is required to rule out any bladder erosions. The vesical stone formation due to intravesical mesh erosion of a mid-urethral sling is rare. Bladder stones almost invariably develop if the exposed mesh has been present for > 3 months.
In our cases, after the endoscopic fragmentation of the stone, the cauterization and resection of the mesh with adherent bladder mucosa of the bladder wall was performed. In addition to the possibility of the transvesical and intramural placement of the tape during the original procedure, it is postulated that the high abdominal pressure and the near passage of the unbraided tape to the bladder wall may facilitate the erosion of the tape. Owing to the paucity of the data on mesh erosion, there is no consensus regarding the ideal method of mesh removal and subsequent surgical correction. In the majority of reported cases, open surgery with complete or partial removal of the mesh was the preferred treatment modality [4]. However, recent successful endoscopic management of the bladder perforation by mesh was reported in 3 cases [4,5]. Therefore, we believe that endoscopic management of the eroded mesh should be the first choice of therapy, and if it failed, open surgery can be tried.
These case reports describe an erosion of mid-urethral tape after 18 and 22 months, which is uncommon. The late appearance of the erosion emphasizes the importance of long-term follow-up, and these reports show that partial excision of the exposed mesh can still result in further recurrence of an erosion area.
In conclusion, the persistence of stress urinary incontinence or lower urinary tract symptoms after mid-urethral slings requires attention to the possibility of bladder or urethral erosion by the mesh. The endoscopic management of the eroded mesh should be the first choice of bladder erosion therapy. Careful and comprehensive urethrocystoscopy is mandatory during mid-urethral sling procedures. There is a need for long-term follow-up of patients with mid-urethral slings. The optimum method of the mesh excision has not been determined.
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