Pelvic Pain Syndromes / Sexual Dysfunction
Persistent pain after TVT-O procedure is a rare complication. It is suspected that nerve injuries are a cause of persistent pain. Management of such complications is difficult, and there is no common surgical approach to the task of resolving them. The aim of this video is to provide a step-by-step description of our approach to laparoscopical removal of transobturator tape in patients with de novo postoperative neurological pain.
A 35-year-old woman (G2/P2) was referred to our department one year following transobturator tape procedure with persistent urinary leakage, dyspareunia and pain irradiating to the thigh, with pain increase with sitting. In the upright position the pain ceased. All those symptoms followed the insertion of transoturator tape in 4/2016. Pain disappeared after the pudendal block.
Laparoscopy was performed, using a 10 mm port inserted in the inferior edge of the umbilicus to accommodate the laparoscope and three other ports (one 10 mm and two 5 mm). After filling the urinary bladder with 150 ml of sterile saline, the peritoneum was opened and the Retzius space was reached. Tape was identified in the right obturator fossa, and transvaginal palpation helped to identify the course of the tape. The tape was dissected and cut near the obturator muscle, dissected step by step under visual control. The appropriate tension on the dissected tape allowed complete removal of the tape.
The postoperative course was uneventful. The pain disappeared immediately after the procedure. The patient was discharged from hospital on the second day after surgery. In follow-up visits 3 and 6 months after surgery the patient reported experiencing no pain: the dyspareunia had disappeared, and there were persistent OAB symptoms and partial relief was provided by parasympatholytic treatment (Solifenacin 5 mg). Control urodynamics six months following surgery excluded urodynamic stress urinary incontinence.
Aberrant passage of the tape during surgery may induce different types of complications: one of them is persistent pain. Irritation of obturator nerve is generally suggested as the cause of persistent pain. However, in many cases this pain is due to irritation of the pudendal nerve or its branches. Management of the persistent pain after surgery is complicated, and it is recommended to start the treatment with oral analgesics and physical therapy. Tape removal is a secondary option. For patients with a history of persistent pain over 6 months, surgical revision and tape removal should be offered as first-line treatment. The patient is offered transvaginal removal or a combined approach together with thigh dissection; in many cases the transvaginal approach alone is inadequate, and there is likely to be irreversible nerve damage or pain persistence. The transvaginal approach only makes it possible to dissect the tape up to the lateral pelvic wall. This makes the nerve irritation less intensive, but the remnants of the tape are still in contact with the nerve.
Laparoscopy removal is an effective, minimally invasive option for management of persistent pain, especially for patient with pudendal nerve irritation.