Ordorica, Rodriguez, Coste-Delvecchio, Hoffman, Lockhart 2008
The authors of this paper report an increase in the number of women being referred with disabling complications after conservative treatment for problems following sling surgery has failed. Synthetic slings are currently the standard surgery for women with stress urinary incontinence (SUI). They have become popular because they do not require tissue from the patient’s own body, the surgical time is shorter, and the slings are thought to produce similar results to autologous slings (made out of material from the patient’s own body). The authors discuss complications after synthetic slings – presentation, surgical treatment and results.
Twenty-five of the thirty-nine patients in this case series had synthetic slings. Out of all slings implanted, twenty of the thirty-nine patients presented with bladder outlet obstruction, 13 with sling erosion, three with worsened SUI, and two (5%) with unobstructive severe urgency and frequency.
Synthetic slings were the most common sling material causing bladder emptying problems. Among the obstructed group (20 women), 12 resumed normal voiding and were continent after surgery. The failures after cutting the sling were linked to persistent bladder instability and/or uncorrected obstruction. Cutting or releasing the sling requires a very careful dissection between the urethral wall and the sling. Occasionally, the sling can be embedded in the urethral wall and there is possibility of urethral perforation. Closure requires urethral reconstruction with three layers usually, strengthened with a Martius or a vaginal flap.
Previous conservative treatment was not successful in those patients with voiding dysfunction characterised by disabling frequency, urgency and a slow, intermittent stream. The best way to identify urgency and frequency after placing a sling is through a free flow rate. The urodynamic pattern of high voiding pressure/low flow is rare in women with urethral obstruction after a sling procedure. In these cases, the maximum flow rate is low and voiding seems to be intermittent, occasionally with intra-abdominal effort. Occasionally patients refer to pain in the area of the sling while receiving a pelvic examination.
Erosion of synthetic material into the vagina is usually accompanied by vaginal discharge, infections, painful intercourse and/or pelvic pain. Small asymptomatic erosions may be treated with oestrogen cream which might enable a layer of vaginal mucosa to grow and cover the sling. Symptomatic erosions require removal of all the eroded material, and in cases of fistula with vaginal secretion, the uneroded sling material with suspending sutures needs to be removed.
The authors conclude that the complication rate with peri-urethral synthetic slings is substantial. Patients with hard to treat urgency/frequency after the sling need a complete evaluation with cystoscopy and video-urodynamics. Obstruction and erosion are the commonest problems and require surgical correction.