Hypothesis / aims of study
Since the introduction in 1995 of the tension-free vaginal tape (TVT) by Ulmsten, and later the transobturator tape (TOT) introduced in 2001 by Delorme, this minimally invasives therapies for stress urinary incontinence (SUI) in women has developed into a widely used and effective procedure, with high cure rates. As the sling implantation procedure consist in blind insertion of trocar and synthetic material, it carries a risk of perforation/erosion into the vagina, urethra or bladder. Mesh erosion into the genitourinary tract following this surgery is relatively rare, but is a potentially serious complication; the reported incidence of bladder/urethral mesh erosion is 1-3% . Polypropylene mesh in contact with urine leads to incrustation (associated with infection, bleeding, inflamation), so the eroded mesh must be removed. Traditional open resection is complicated and morbid. Several endoscopic techniques has been used: standard transurethral electroresection, pneumatic lithotripsy, endoscopic resection laparoscopically assisted, and transurethral endoscopic excision using the holmium laser (TEEH) (described in 2004 by Hodroff, wich since has been employed in small case report series, with variable success, and limited follow-up) [2-3].
The aim of this study is to evaluate the efficacy and security of the TEEH, in women with previous antecedent of stress urinary incontinence surgery with midurethral slings or other pelvic surgery.
Study design, materials and methods
Between March 2010 and July 2018, a retrospective series of 21 women were identified, presenting with dysuria/micturition pain (48%), recurrent urinary tract infections (28%) and urgency/frequency storage symptoms (24%). Cystoscopy was performed, finding endoluminal eroded sling in 18 patients (10 TVT, 6 TOT, 2 REMEEX), and non-absorvable suture in 3 patients (other pelvic surgeries). Localization of the erosion was predominantly at urethra and left bladder wall (67%). The procedures were performed under spinal anesthesia. Patients underwent TEEH with 26ch 2 ways continous flow resectoscope, 550-μm Ho:Yag laser fiber and settings of 1.5–2 J / 10–30 Hz. Associated stones were managed with laser lithotripsy prior to the mesh excision. The mesh or suture were excised to the level of mucosa continued at the submucosa until there was no remaining visible material. A bladder catheter was left after the procedure. Outcomes included resolution of symptoms, and successful treatment was defined by the absence of exposed mesh at the cystoscopy.
The mean age was 69 years (50-83). Median time between the incontinence/pelvic surgery and beginning of symptoms was 108 months (12-345), and 17 months (4-135) from the beginning of symptoms until the Holmium Laser surgery. Mean time for the surgery was 46 minutes (16-101), and 1,38 days (1-3) for the hospital discharge. Median bladder catheterization was 2 days (1-36). No complications associated with the procedure were registered. Control cystoscopy were performed 1-3 months after the procedure, with normal result in 90% (19 patients); only 2 patients with persistence/recurrence of the erosion were re-treated (1 TVT, 1 TOT). Median follow up was 21 months (12-80). All patients reported resolution of the initial symptomatology, after a normal cystoscopy. The recurrence of SUI after the procedure was reported in 2 patients (representing 11% of the SUI previously treated patients).
Interpretation of results
In our retrospective review, we identified patients with genitourinary voidyng symptoms or recurrent UTI, associated with the antecedent of SUI sling surgery or other pelvic surgeries. The finding of endoluminally eroded mesh or sutures , led us to perform a TEEH treatment with high success rate, none serious complications, and low recurrence for SUI, as previously described in literature.
Patients with urinary mesh/suture erosions, can be managed among other techniques, with the minimally invasive TEEH.
SUI is a potential complication of any intervention for mesh erosion (with greater mesh resection, greater the risk for recurrence of SUI). Recognition of this is important for preoperative patient counseling.
In our experience, TEEH is an effective and safe method for the treatment of SUI slings and sutures (eroded at the bladder or urethra), with a high rate of symptomatically and functional long term results.