Vaginal erosion, sinus formation, and ischiorectal abscess following transobturator tape: ObTape implantation

A 50-year-old woman was referred for evaluation with an 8-month history of intermittent malodorous vaginal discharge initially noted 2 months after placement of a transobturator tape for stress urinary incontinence. Evaluation revealed erosion of the tape through the vaginal wall with a sinus tract associated with an ischiorectal abscess. Surgical removal of the tape with excision of the sinus tract, drain placement, and antibiotic therapy was needed for complete resolution of the symptoms. Infectious complications need to be considered when counseling women prior to synthetic sling placement. A high index of suspicion, meticulous sub- and periurethral inspection, along with aggressive surgical management are required to treat an infected draining abscess following synthetic transobturator sling placement.     

A late complication of transobturator tape procedure: vaginocutaneous fistula formation with vaginal mesh erosion

Transobturator tape procedures are a common treatment modality in patients with stress urinary incontinence (SUI). Various complications have been reported related to this procedure. We present a rare case of vaginocutaneous fistula formation 5 years after transobturator tape surgery. A 56-year-old woman presented with complaints of increased vaginal discharge, difficulty in coitus, and serosanguineous discharge from the left groin 5 years after transobturator tape surgery for SUI. Pelvic examination revealed 2–3 cm of extruded mesh at the anterior vaginal wall. The vaginocutaneous fistula was detected at surgery. The suburethral tape was removed, and the fistula tract was excised and repaired primarily. Postoperative period was uneventful, and the patient was still continent 6 weeks postoperatively. With widespread use of mesh for treating SUI, we will likely see a variety of complications in the long term.     

Groin abscess secondary to trans obturator tape erosion: case report and literature review

AIMS: To report a case of groin abscess secondary to trans obturator tape erosion and review the literature on the incidence, predisposing factors, symptoms and management of tape erosion. METHODS: The clinical history, operative details, postoperative symptoms, findings and management of this case are reported. A thorough literature review of midurethral tape erosions and, in particular, transobturator tape erosions was performed. RESULTS: A 46-year-old woman with urodynamic stress incontinence underwent trans obturator tape insertion. Eight weeks later she developed vaginal discharge and was subsequently diagnosed with a left lateral vaginal wall tape erosion. The eroded section was excised under general anaesthetic. Two weeks later she presented with a large right sided groin abscess which required incision, drainage and debridement of necrotic areas of gracillis and adductor muscles. Short term results following trans obturator tape insertion report excellent efficacy rates (90-96% after 1 year), however there is a lack of long term data on safety and efficacy. Current literature on transobturator tape erosion is scanty and reported rates range from 1.9-7% depending on the tape inserted. Tape erosion commonly presents with vaginal discharge, bleeding or dyspareunia and several methods of management have been reported including conservative management, excision of the eroded section or removal of the entire tape. CONCLUSIONS: Groin abscess following tape erosion is a serious complication resulting in further surgery and months of morbidity for the woman. Prompt management of tape erosion is essential to minimise such complications and more data is required on the long term efficacy and safety of transobturator tapes.     

Chronic vaginal discharge and left leg edema after a transobturator tape procedure

We report on a patient who underwent total vaginal hysterectomy for urinary incontinence 8 years previously with a sling operation using transobturator tape (TOT). She was admitted to our hospital after complaints of vaginal discharge, foul odor, and bleeding, left thigh pain, and edema. Magnetic resonance imaging (MRI) and computed tomography (CT) revealed a fistula tract from the vagina or urethra with remnant sling tape. We removed the remnant tape using intraoperative ultrasonography. This case exemplifies the rare occurrence of a vaginal fistula extending to the obturator, adductor, and pectineus muscles combined with myositis after TOT placement. It is important that urogynecologists recognize that TOT procedures may result in complications accompanied by common recurrent vaginal symptoms, such as vaginal odor and spotting, which can be identified by MRI or CT.     

Perineal cellulitis and persistent vaginal erosion after transobturator tape (Obtape)—case report and review of the literature

Transobturator sub-urethral tapes are emerging as one of the surgical options for the management of urodynamic stress incontinence. Though with relatively less risk of injury to the bladder, a different approach as well as the different characteristics of the tape material mean a variety of complications like obturator abscess, obturator haematoma, retro-pubic haematoma, and perineal cellulitis. In this paper, we describe a case of perineal cellulitis following the insertion of a transobturator tape (Obtape®). Though cellulitis was managed conservatively with intravenous antibiotics, the patient was found to have vaginal extrusion of the tape. Vaginal erosion was initially managed with resuturing of the vaginal wall. Persistent erosion unfortunately necessitated complete tape removal. The patient later had another sub-urethral procedure after 3 months. Perineal cellulitis is rare after transobturator tape procedures. In the literature, only two cases have been described so far. Though vaginal erosion can be managed conservatively, we recommend the complete removal of the tape when an infection is proven or suspected.     

Management of persistent groin pain after transobturator slings

Prolonged groin pain after transobturator tape is uncommon. Three women reported groin pain that had not improved by 3 months postoperatively. Combined steroid and local anesthetic was effective for pain relief in all patients. The differential diagnosis of persistent groin pain after transobturator tape includes adductor muscle strain, osteitis pubis, obturator/groin abscess, structural adhesions, and inflammation, edema or nerve entrapment of the anterior branch of the obturator nerve. No side effects of treatment were noted. Patients that do not respond to local injection may require mesh dissection and excision.     

A prospective trial comparing tension-free vaginal tape and transobturator vaginal tape inside-out for the surgical treatment of female stress urinary incontinence: 1-year followup

PURPOSE: We prospectively compared the efficacy and safety of tension-free vaginal tape and transobturator vaginal tape inside-out for female stress urinary incontinence. MATERIALS AND METHODS: A total of 120 women with stress urinary incontinence were alternately assigned to the tension-free vaginal tape group (60) or the transobturator vaginal tape inside-out group (60). Preoperative evaluation included urodynamic study and a Korean version of the incontinence quality of life questionnaire. One year after operation the surgical result, patient satisfaction, incontinence quality of life questionnaire, long-term complications and uroflowmetry were evaluated in the 2 groups. RESULTS: Patient characteristics were comparable in the 2 groups. Mean +/- SD operative time was significantly shorter in the transobturator vaginal tape inside-out vs the tension-free vaginal tape group (11 +/- 1.4 vs 15 +/- 1.8 minutes). In the transobturator vaginal tape inside-out and the tension-free vaginal tape groups the rates of cure (86.8% and 86.8%), improvement (6.6% and 8.2%) and failure (6.6% and 5.0%, respectively) were similar. Incontinence quality of life questionnaire parameters 1 year after surgery were improved significantly in each group and there was no difference between the 2 groups (p <0.001 and >0.05, respectively). There was no long-term complication in either group. Preoperative urge incontinence resolved in 80% of the tension-free vaginal tape group and in 100% of the transobturator vaginal tape inside-out group. De novo urgency developed in 4 patients (6.6%) in the transobturator vaginal tape inside-out group. CONCLUSIONS: The tension-free vaginal tape and transobturator vaginal tape inside-out procedures were minimally invasive and similar in operation related morbidity. Transobturator vaginal tape inside-out appeared to be as effective and safe as tension-free vaginal tape for the surgical treatment of stress urinary incontinence in women at 1-year followup.     

Abscess formation at the ischiorectal fossa 7 months after the application of a synthetic transobturator sling for stress urinary incontinence in a type II diabetic woman

A 50-year-old diabetic woman was referred to our unit because of high fever, foul-smelling vaginal discharge and pain in the leg, 7 months after undergoing surgery for application of a transobturator suburethral sling. Patient evaluation revealed erosion of the tape through the vaginal wall; the infection had spread to the region of the internal obturator muscle and then up to the anterior recess of the ischiorectal fossa. The patient underwent surgery for sling removal, antibiotic therapy and, finally, surgical incisions to facilitate drainage of the abscess. All these passages were necessary to obtain complete resolution of the symptoms. Infectious complications are possible after transobturator sling procedures. Patients should then be informed about the risks of erosion and infection and be warned that the appearance of pain and foul-smelling vaginal discharge may indeed be the first symptom of subsequent and much more severe infectious complications.     

Groin abscess due to a forgotten midurethral sling connector

Midurethral slings (MUS) have been used for female stress urinary incontinence throughout the past decade on a worldwide scale. Although this minimally invasive treatment has high success rates, formation of groin abscesses, as well as vaginal and urethral erosions, can occur after the procedure. We report a patient presenting with groin abscess and sinus tract formation after a transobturator tape procedure. The patient exhibited a swollen sinus tract, which drained the abscess at the site of the tape entry to the obturator foramen within her inner left groin. She was referred to our department after unsuccessful medical and surgical treatments. Surgical exploration revealed a forgotten MUS connector located between the mesh and hook within the skin incision. To the best of our knowledge, this is the first report of such a case.     

Prepubic and thigh abscess after successive placement of two suburethral slings

We present a case of prepubic and thigh abscess after the placement of two types of suburethral slings in a 65-year-old woman suffering from stress urinary incontinence (SUI). The first surgical procedure (prepubic tension-free vaginal tape) was unsuccessful. Thus, 2 months later, we placed an ObTape sling by transobturator approach. This second procedure was successful. Seven months later, the patient presented with vaginal erosion of the sling with no inflammatory signs. The suburethral portion of the sling was immediately removed and the vagina was sutured. Nine months later, a prepubic abscess occurred and required removal of the prepubic sling, drain placement, and antibiotic therapy. Unfortunately, 9 months later, a thigh abscess occurred. Magnetic resonance imaging (MRI) allowed precise diagnosis and anatomic localization of the thigh abscess. Surgery consisted of opening and draining the abscess and removing the transobturator sling. At 6 months follow-up, no persistent inflammatory sign was observed on MRI, and SUI did not recur.     

Suburethrale Bänder TVT und TOT

The introduction of tension-free vaginal tapes has led to a complete change of surgical therapy in female urinary stress incontinence. Different materials are used. In many departments, the classic TVT procedure with retropubic placement of the tape has been replaced by transobturator procedures. The current discussion involving transobturator tapes focuses on the question of whether the inside-out technique or the outside-in technique leads to significantly different results. Current state of the art is that all techniques are almost comparable concerning treatment success and complications. Depending on possible pretreatments or concomitant diseases that result in a higher risk for complications, the decision for one technique can be taken individually for each patient. In patients suffering from recurrent stress urinary incontinence after implantation of a tension-free tape, the retropubic implantation of a TVT seems to be superior to a transobturator tape.     

Necrotizing fasciitis following transobturator tape procedure: a case report and literature review

A 51-year-old diabetic woman was referred to our unit with a history of increasing pain in her right thigh and gait disturbance, 10 days following surgery for treatment of stress urinary incontinence with a transobturator tape. Examination elicited a tender right thigh associated with swelling and erythema. Inspection of the vagina revealed an exposed mesh through the vaginal erosion. Plain radiographs and magnetic resonance imaging revealed large thigh abscesses suggestive of gas gangrene from the pelvis to the calf. The mesh was completely removed; extensile incisions, as well as aggressive debridement of all necrotic tissue in the thigh and calf, were performed. A diagnosis of necrotizing fasciitis with gas extending to the lower leg level was confirmed. After mesh removal, abscess drainage and debridement, the patient recovered with antibiotics and daily wound care. Three months after the operation, the patient showed no recurrence of the infection.     

Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh

PURPOSE: We studied the diagnosis, management and prognosis of vaginal mesh erosion using a thermally bonded nonwoven polypropylene mesh in a transobturator suburethral tape procedure for the surgical treatment of stress urinary incontinence in women. MATERIALS AND METHODS: A total of 65 patients diagnosed with stress urinary incontinence underwent a transobturator suburethral tape procedure with a fusion welded, nonwoven, nonknitted polypropylene mesh, with or without a central silicone coated section, at our institution. All women were followed and if vaginal erosion was diagnosed, cystoscopy and vaginoscopy were performed, the mesh was partially or completely removed and, if necessary, posterior cough test and urodynamic study were performed. RESULTS: Of the 65 patients 9 (13.8%) were diagnosed with vaginal erosion at the vaginal incision during a relatively long postoperative period (mean 290 days). All presented with vaginal discharge and 1 had a severe complication (obturator abscess). Complete mesh removal was necessary in 8 patients and only 2 (22%) had recurrent stress urinary incontinence. CONCLUSIONS: A 13.8% rate of vaginal mesh erosion using a nonwoven thermally bonded polypropylene mesh was reported. This complication was probably due to the characteristics of the mesh and not to the transobturator approach. Complete removal of the tape is recommended and the continence status prognosis is good (78%).     

Infected midurethral tape presenting as an ischiorectal abscess

This is the first reported case of an ischiorectal abscess after a midurethral intravaginal slingplasty (IVS). The patient presented with recurrent ischiorectal abscess which was initially thought to be an unusual presentation of a fistula in ano. Subsequent examination under anaesthesia, however, revealed a fistulous tract extending from the right postero-lateral perianal opening to the vagina where the tape was noted to be eroded and infected. The abscess healed only after removal of the source of infection i.e. the IVS tape. In this report, we also discuss the two main types of meshes used as midurethral slings, the ways in which they differ and the arguments for and against using them.     

Monarc transobturator sling system for the treatment of female urinary stress incontinence: results of a post-operative transvaginal ultrasonography

The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN–S) and the BN–S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 ± 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 ± 3.1 mm in the transobturator plus hysterectomy group and 12 ± 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.     

Large thigh abscess after placement of synthetic transobturator sling

PURPOSE: To report a unique complication associated with transobturator slings. MATERIALS AND METHODS: The evaluation and treatment of a unique infectious complication of transobturator slings is reviewed. RESULTS: A large thigh abscess associated with a transobturator sling was diagnosed and treated. CONCLUSION: New techniques of sling placement may be associated with unique infectious complications. Slings passing through the obturator foramen and thigh can lead to a significant abscess within the adductor muscles of the thigh.     

A three-incision approach to treat persistent vaginal exposure and sinus tract formation related to ObTape mesh insertion

Mentor Corporation's ObTape has been associated with considerable morbidity. An unacceptably high exposure rate has been noted, and in some cases, multiple procedures may be necessary for complete mesh removal.We evaluated a patient who had prior ObTape placement complicated with persistent vaginal discharge and granulation tissue formation related to persistent mesh exposure (3Bc-T2-S2) followed by sinus tract formation (6Cd-T3-S3) according to the International Urogynecological Association Classification. We performed a three-incision approach (abdominal, vaginal, and groin) for the complete removal of the retained portion of the transobturator tape. This three-incision technique represents a viable option for removal of transobturator tape causing persistent clinical issues.     

Treatment of voiding dysfunction after transobturator tape procedure

Voiding dysfunction after mid-urethral sling procedures is uncommon but not completely avoidable. We report on a method to adjust the transobturator mid-urethral sling under local anesthesia in the early postoperative period for postoperative voiding difficulty. At postoperative day 17 and 18, 2 women, who had undergone the transobturator tape procedure for stress incontinence, underwent successful loosening of the mesh through the previous vaginal incision, without the need to transect or remove the tape. Both patients had immediate resolution of their symptoms while maintaining urinary continence.     

两种术式治疗肛周脓肿的对比观察

目的对比观察一期根治术与单纯切开引流术治疗肛周脓肿的临床疗效。方法通过回顾性分析对照研究162例肛周脓肿患者,其中治疗组106例采用一切根治术,对照组56例采用单纯切开引流术。结果治疗组治愈率达95.28%,肛瘘发生率4.72%;对照组治愈率33.93%,肛瘘发生率66.07%,治疗组肛瘘发生率明显低于对照组,有显著性差异(P0.01)。对照组仅19例治愈,且治愈者均为低位、浅表脓肿,分别为肛周皮下脓肿10例,低位肌间脓肿9例。未愈或形成肛瘘者根据肛瘘手术方式,低位采用肛瘘切开术,高位采用肛瘘切开挂线术。除对照组有3例括约肌上瘘经第3次手术治愈外,其余均于第2次手术后治愈。结论一期根治术治疗肛周脓肿对防止术后肛瘘的形成有较明显的效果。     

两种入路尿道中段悬吊术治疗女性压力性尿失禁的临床效果比较

目的 比较经耻骨后和闭孔入路经阴道尿道中段无张力悬吊术治疗女性压力性尿失禁的临床效果和并发症.方法 应用经阴道尿道中段无张力悬吊术治疗女性压力性尿失禁患者134例,根据手术入路的不同分为两组:耻骨后组(32例)和闭孔组(102例).对两组的手术时间、失血量、治愈率和有效率以及术后并发症进行比较.结果 耻骨后组和闭孔组的手术时间分别为(24±6)min和(22±5)min,术中失血量分别为(45±27)ml和(54±23)ml,治愈率分别为81.25%和78.43%,有效率分别为96.88%和98.04%,两组比较差异无统计学意义(P＞0.05).两组术后并发症的发生率分别为:新发尿急6.25%和5.88%,排尿困难:3.13%和2.94%,膀胱损伤:3.13%和0%,阴道损伤:0%和2.94%,两组比较差异无统计学意义(P＞0.05).术后腹股沟疼痛的发生率分别为3.13%和20.59%,两者差异有统计学意义(P＜0.05).结论 耻骨后入路和闭孔入路尿道中段悬吊术均是治疗女性SUI的有效术式.