Hypothesis / aims of study
This is a first report to present an unusual cystoscopic finding, named the “Central Road”, following laparoscopic sacrocolpopexy (LSC). In 2011, the U.S. Food and Drug Administration (FDA) released a safety communication on mesh-related complications, and transvaginal mesh prolapse operation (TVM) decreased and was replaced by other procedures such as LSC in the U.S. and Europe thereafter. In Asian countries, while TVM remains as a core surgical option due to relatively low reported complication rates, more doctors tend to perform LSC, especially for sexually-active or younger patients. As LSC is increasing, problems associated with LSC are starting to be discovered. We present a cystoscopic finding (the "Central Road") caused by excessive tension on the LSC mesh in a woman who had severe mixed urinary incontinence (MUI) following LSC.
Study design, materials and methods
A 70-year old woman developed severe MUI immediately after LSC. Her cystoscopy revealed an unusual cord-like elevation resembling a "Central Road". Patient details were analyzed and examinations including videourodyanamics and cystourethrography were done before and after transobturator tape operation (TOT) to treat stress urinary incontinence (SUI).
She underwent LSC due to stage III uterine prolapse and cystocele. After subtotal hysterectomy, anterior and posterior mesh were fixed to the vaginal walls and the uterine cervix was fixed to the sacrum (promontorium) with mesh. A cough stress test during prolapse reduction was negative preoperatively, so she did not undergo concomitant anti-incontinence surgery. Although only occasional MUI occurred before LSC, severe MUI developed immediately after LSC: SUI 5-6 times a day, and urgency urinary incontinence (UUI) 1-2 times a day. She had urinary incontinence with coughing, sneezing, walking, and physical exercise such as stretching and jumping. When she coughed successively, she had massive incontinence with urinary urgency. While using 80 cc urinary pads, she had to change them 4 times a day. Anticholinergic medication was effective to decrease the amount of UUI. Then, she underwent a cystoscopy, which revealed no mesh exposure or tumor but a cord-like elevation in the center of the trigon and posterior wall resembling a "Central Road" (Fig. 1). A cough stress test showed massive leakage synchronized with coughing, and a one-hour pad test showed 44.1g/hr. of leakage. Uroflowmetry was normal: Qmax 23.7 ml/s, voided volume 491 ml, and residual volume 22 ml. Videourodynamics showed urodynamically proven SUI (Valsalva leak point pressure 147 cmH2O) but no detrusor overactivity under anticholinergic medication. Chain cystourethrography was unusual; the proximal urethra was open, and both upper urethral angle and posterior vesicourethral angle were widened in an atypical way (Fig. 2), which indicated that posterior vesical wall and proximal urethra were pulled excessively in the direction of the sacrum by the LSC mesh. Finally, 18 months after LSC, the patient underwent TOT under general anesthesia. During 6 months of follow-up, both SUI and UUI were completely relieved without medication, and no urinary pads were necessary. Cough stress tests became negative and residual volume remained normal. Videourodynamics showed no urodyanamically proven SUI or detrusor overactivity.
Interpretation of results
Prolapse operations are known to cause worsened or de novo SUI by relieving obstruction by the prolapse. However, there are also iatrogenic factors. Excessive tension on the LSC mesh, resulting in a “Central Road” finding, can cause an opening of the bladder neck, and worsening of SUI and possibly UUI (stress-induced instability). Loosening of the LSC mesh might be necessary in some cases though midurethral sling procedure was sufficient to treat MUI in this case.