Transobturator tape erosion associated with leg pain

A 39 year-old vaginal multipara status postpubovaginal sling in 2002 and a transobturator tape procedure in 2004 presented with persistent stress incontinence and vaginal polypropylene mesh erosion. Ten days later, she presented to the emergency room with severe right groin pain, difficulty walking, fever, and chills. She described shooting pain originating from the right inguinal ligament radiating down her right leg anteriorly. Although her neurologic examination was normal, palpation of the right obturator internus muscle reproduced her pain. MRI clearly revealed the course of the mesh tape through the obturator muscles and marked increase in the size of the right adductor and obturator internus muscles, apparently compressing the adjacent neurovascular fascicle. The patient was taken to the operating room where the polypropylene tape was easily removed through the vaginal erosion. Mesh cultures were positive for bacteroides fragilis. She experienced complete symptom resolution within 1 week of tape removal.     

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.     

Persistent groin pain following a trans-obturator sling procedure for stress urinary incontinence: a diagnostic and therapeutic challenge

Groin pain after a tension-free vaginal tape–obturator (TVT-O) procedure can occur but mostly disappears within 4 weeks. Persistent groin pain is extremely rare and there is a paucity of literature on how to diagnose and manage this adverse event. We present two cases with severe persistent groin pain after uncomplicated TVT-O, in which magnetic resonance imaging and electromyography did not reveal the cause. We concluded that the tape entrapped or cut through peripheral branches of the obturator nerve. We removed as much of the tape as possible in both cases. Removal partially relieved the pain although sensory loss of the obturator nerve persisted 1 year after surgery. In case of abnormal post-operative groin pain, soon removal of the tape enhances the chance that damage to the obturator nerve is reversible, although it is important to counsel patients with similar pathology that recovery can take long and may be only partial.     

Recurrent obturator abscess with spontaneous expulsion of the mesh after transobturator tape operation

The transobturator tape operation has been the most popular method of SUI surgery worldwide owing to its low complication rate and high success rate. However, erosions and abscesses secondary to transobturator tape have been observed. Here we report a 36-year-old woman referred to our unit with fever, persistent swelling in the left groin, difficulty in walking, and a tape that came through the vagina, 4 years after the transobturator tape operation. She had a history of ischiorectal abscess and rectovaginal fistula. A recurrent obturator abscess with fistula formation and spontaneous expulsion of the mesh was diagnosed. The patient underwent antibiotic therapy, incision through the fistula tract, drainage of the abscess, and removal of the necrotic material. Patients should be informed about risks of erosion and infection and that pain and foul smelling vaginal discharge might be the first signs of severe infectious morbidities after transobturator tape operation.     

Transient obturator neuropathy due to local anesthesia during transobturator sling placement

The transobturator tape procedure is a popular minimally invasive procedure to treat stress urinary incontinence. A 42-year-old woman with stress urinary incontinence underwent a transobturator sling under intravenous sedation and local injection with a mixture of 0.5% bupivicaine and 1% lidocaine with 1:200,000 epinephrine. After surgery, she had difficulty with adduction of the left leg, consistent with a left obturator neuropathy, which improved after approximately 12 h and completely resolved by the next day. Although the transobturator tape is an effective, minimally invasive procedure that may be performed on an outpatient basis, caution should be used in the dosage, type, and amount of local anesthesia used. Post-operative obturator paralysis can be expectantly managed as the symptoms should resolve after the local anesthesia wears off. An erratum to this article can be found at     

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.     

De novo pudendal neuropathy after TOT-O surgery for stress urinary incontinence

Background and Objectives:

Five cases of pelvic nerve complications after transobturator tape (TOT) inside-out surgical procedures for stress urinary incontinence are presented.

Methods:

We conducted a chart review of patients with complications referred to our practice.

Results:

Five patients with nerve complications after TOT inside-out procedures were investigated. Pudendal neuropathy and interstitial cystitis were seen in this series of patients with several patients having myofascial pain in the lower abdominal area.

Conclusions:

Although not commonly reported, complications from needle placement and from the area of needle exit in a TOT procedure can exist, and the surgeon must be careful when placing the needle through the area of the obturator fossa.     

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.     

Obturator nerve injury: a rare complication of retropubic tension-free vaginal sling

The tension-free vaginal tape (TVT) retropubic sling is a very effective treatment for stress urinary incontinence. High cure rates are typically achieved, and the reported complication rate is relatively low. Obturator neuralgia secondary to insertion of a midurethral sling is a rare and specific type of chronic pain that is more commonly associated with transobturator tape slings. The purpose of this video case report was to demonstrate that obturator nerve injury is a possible complication of TVT retropubic slings placement. A discussion of symptoms and signs of obturator nerve injury and how these should be managed is also presented.     

Pre-ramus passage of inside–out transobturator sling

Groin pain after transobturator tape is not uncommon. Differential diagnosis and treatment strategies are becoming elaborated in the literature. A patient presented with partial improvement in her stress incontinence and persistent groin and vulvar discomfort for 3 months after “inside–out” transobturator tape. The sling was removed secondary to malposition anterior to the inferior pubic ramus, i.e., a trans-vulvar passage. Her vulvar and groin complaints resolved. Recommendations are made to facilitate the “inside to out” transobturator dissection and trocar passage to prevent this complication.     

Anatomical variability in the trajectory of the inside-out transobturator vaginal tape technique (TVT-O)

An experimental surgical study on human cadavers was undertaken to assess variability in the trajectory followed by the needle during application of the inside-out transobturator tape suspension (TVT-O) technique. The TVT-O surgical procedures were performed on six fresh female cadavers according to the standard recommended operative protocol. Subsequent anatomical dissection revealed that the needle had perforated the obturator membrane at a distance of 0.7 to 2.0 cm from the needle to the obturator canal. It subsequently followed a variable course passing at 0.5 to 2.0 cm from the anterior branch of the obturator nerve and 0.1 to 1.4 cm from the posterior branch. We conclude from this anatomical study that the TVT-O trajectory is subject to wider variability than was originally postulated. Both P. Hinoul and S. Smajda contributed equally to this paper.     

Transobturator vaginal tape inside out for the surgical treatment of female stress urinary incontinence: anatomical considerations

PURPOSE: We have recently described a novel surgical technique for female stress urinary incontinence, that is the transobturator vaginal tape inside out, which uses specific instruments for the passage of a synthetic tape from beneath the urethra toward the thigh folds. Herein we report the results of cadaver dissection performed to determine the anatomical trajectory of the tape and its relationships with neighboring neurovascular structures and organs. MATERIALS AND METHODS: Insertion of the transobturator vaginal tape inside out tape was performed by different surgeons in 12 freshly frozen female cadavers according to the standard procedure. The thigh, obturator, perineal and pelvic regions were dissected and tape trajectory was recorded. An additional cadaver was dissected without prior tape placement. RESULTS: The tape was inserted according to a certain consistent path, that is penetration from the suburethral space into a strictly perineal region limited medial and cranial by the levator ani muscle, caudal by the perineal membrane and lateral by the obturator internus muscle. This region corresponded to the most anterior recess of the ischiorectal fossa. The tape then perforated the obturator membrane and muscles, and exited through the skin after traversing adductor muscles and subcutaneous tissue. The tape was coursed away from 1) the dorsal nerve to the clitoris located more superficially below the perineal membrane, 2) the obturator nerve and vessels, and 3) the saphenous and femoral vessels. CONCLUSIONS: These findings strongly suggest that our transobturator technique is highly accurate, reproducible and safe, and it does not require perioperative cystoscopy.     

Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings

Objectives The objective of the study is to clarify potential risks to the dorsal nerve of the clitoris (DNC) and obturator canal using different minimally invasive slings.Study design Ten embalmed hemipelves were dissected to demonstrate the course of the DNC and the obturator canal. On each cadaver, tension-free vaginal tape (TVT), transobturator in–out (TVT-O) and transobturator out–in (Monarc) procedures were performed. Distances between the DNC and the obturator canal to the different devices were measured.Results The DNC passes beneath the pubic bone at a distance of 14.3±4.7 mm of the midline. The distances of the different devices to the DNC were similar. The distance to the obturator canal was significantly different, with TVT being the furthest (40.1±3.7 mm) and TVT-O the closest (19.3±3.1 mm; p<0.0001).Conclusion Given the course of the DNC along the medial aspect of the ischiopubic ramus, the out–in technique may be safer. The in–out technique is the closest to the obturator canal.     

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.     

采用尿动力学评估TVT—O治疗SUI术后近期疗效

目的：探讨采用尿动力学检查评估经闭孔尿道中段无张力悬吊术（TVT-O）治疗女性压力性尿失禁（SUD近期疗效的作用。方法：选取经TVT-O治疗的女性SUI患者50例．平均年龄（55．1±7．53）岁。全部患者术前和随访时填写国际尿失禁咨询委员会问卷简表（ICI-Q-sF）并行尿动力学检查．比较手术前和随访时各参数的变化。结果：成功随访33例,平均随访1．2．7个月。与术前相关指标比较。术后ICI—Q-sF评分和最大尿流率显著低于术前[术后（0．2±0．1）vs术前（14．6±3．2）。术后（26．4±5．5）ml／sVS术前（30．6±8．1）ml／s,P〈0．05];而术后剩余尿量、最大逼尿肌收缩压、初始尿意、最大膀胱测压容量、膀胱顺应性、最大尿道压、最大尿道闭合压和功能性尿道长度没有显著性改变（P〉0．05）．术中无膀胱及尿道损伤。无闭孔血管神经损伤,无阴道肠管穿孔及血肿等并发症发生;术后并发排尿困难1例（3％）、腹股沟不适2例（6％）及尿急尿频1例（3％）,经对症治疗后好转．手术治愈率和改善率分别为85％（28／33）和12％（4／33）。结论：采用TVT-O治疗女性SUI患者近期效果较好,尿动力学检查是其诊断和疗效评估的有效手段。     

Neuropathy of the obturator nerve as a source of pain in soccer players]

Chronic inguinal and lower abdominal pain in high-performance athletes is common and often disabling problem. Diagnose and treatment is often difficult due to many anatomic structures in the inguinal and groin region that have the potential to cause pain. We report 52 cases of a chronic groin pain in soccer players due to fascial entrapment of the obturator nerve. All patients presented clinical symptoms and signs of post exercise groin, lower abdominal or medial tight pain and adductor muscles weakness and paresthesia in cutaneous distribution of medial thigh. Except clinical signs in the diagnosis of obturator neuropathy we used diagnostic local anaesthetic block and electromyography. In 52 patients the cause of chronic groin pain was obturator neuropathy and they were treated operatively. Surgical neurolysis provided the definitive cure of pain in 41 players.     

An anatomic comparison of the original versus a modified inside-out transobturator procedure

Introduction and hypothesis

The objective of this study was to evaluate the modification of a shortened tape and reduced dissection of the inside-out transobturator procedure on the tape??s relationship to the relevant anatomical structures.

Methods

In ten fresh frozen cadavers, relevant distances between the two different tapes and anatomical structures were recorded.

Results

The shorter tape traversed less muscular structures, but consistently traversed the obturator membrane. The median distance from the tape to the obturator canal measured 2.0 versus 1.9?cm, to the anterior obturator nerve 3.0 versus 2.7?cm, and to the posterior obturator nerve 2.2 versus 2.0?cm [modified versus original procedure, respectively (p?>?0.05)]. Significantly, less mesh was inserted in the modified procedure on each side of the body (6.1 versus 9.9?cm, p?Conclusions The shorter, inside-out transobturator tape traverses less muscular structures than its original counterpart, while still consistently anchoring in the obturator membrane at a similarly safe distance from the obturator canal.     

Transobturator surgery for female stress incontinence: a comparative anatomical study of outside-in vs inside-out techniques

OBJECTIVE To assess the specific risks of injury to neural and vascular structures inherent in two approaches to transobturator surgery for inserting a suburethral sling, i.e. the outside-in (standard technique) and inside-out approaches. MATERIALS AND METHODS The study comprised seven cadavers, providing 14 obturator regions. Five specimens had a tape inserted outside-in on one side, and inside-out on the other; of the remaining two cadavers, one had an inside-out tape and one an outside-in tape, bilaterally. After tape insertion, the cadavers were dissected. Particular attention was paid to the distances between the tape and the deep external pudendal vessels, and between the tape and the posterior branch of the obturator nerve. RESULTS With the inside-out technique, the safety margins were reduced, and the external pudendal vessels and the posterior branch of the obturator nerve were at greater risk of injury. CONCLUSION The two techniques are not equivalent, with a lower risk of injury to vascular and nerve structures with the outside-in technique.     

Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature

The tension-free vaginal tape (TVT) procedure has long been considered the gold standard for female stress incontinence. Since its introduction in 1995, several other tapes and other minimally invasive treatments have arisen. The transobturator tape (TOT) procedure reproduces the natural suspension of the urethra through the obturator and puborectalis muscles. The TOT procedure was reportedly developed in an effort to prevent bladder perforation associated with the TVT and is generally considered to be a procedure with low morbidity. At our institution, we report the first case of infected mesh with subsequent myositis of adductor muscles after a TOT procedure. To our knowledge, this is the first case reporting this complication, citing specifically that the anatomical structures traversed by the tape, including both muscle and fascia, can be at risk for infection and ultimately require removal of the sling material. We performed a MEDLINE literature search using key words such as “transobturator tape,” “tension free vaginal tape,” and “adductor and obturator complications” to ascertain any reported adductor or obturator muscle complications after placement of TOT. Further, we reviewed the literature to elucidate the consequences of using different mesh materials, specifically their effects on erosion. We reported our case of a 43-year-old woman who presented with right-leg cellulitis and vaginal discharge after having a TOT placed for stress incontinence. Inflammation of the adductor muscles was demonstrated on computed tomography (CT) scan and ultrasound. On physical exam, the mesh had visibly eroded through the vaginal wall. Our patient underwent excision of the mesh material. She ultimately had an uneventful postoperative course and was discharged home in good condition on the postoperative day 2. The mesh material removed was ObTape®. We believe our study is the first case report to discuss the complication of infected adductor muscles and erosion of the tape during post-TOT procedure. After a careful review of the literature, there is no mention of myositis of adductor muscles as a possible complication after the TOT procedure. In fact, the literature has deemed this minimally invasive treatment as a safe and effective procedure with minimal complications including only de novo urgency or urinary retention. The site of infection is of particular interest and can be explained by the course through the anatomical structures that are unique to this particular procedure. Ultimately, the treatment for this procedure was the removal of the mesh along with broad-spectrum antibiotics. In conclusion, the burden falls upon the surgeons to report in a timely fashion both successes and complication for the TOT procedure given their relatively limited experience. This is paramount in determining patients’ risks.     

Anatomical risks of transobturator suburethral tape in the treatment of female stress urinary incontinence

INTRODUCTION: The objective of this study was to define the anatomical structures crossed by transobturator tape. MATERIALS: Ten fresh, female anatomical subjects aged 74 to 89 years. METHODS: Transobturator tape was inserted by outside-in way. The position of the tape was verified by perineal and abdominal dissection. RESULTS: Transobturator tape has a transverse course. It crosses the adductor muscles close to their pubic insertion and passes over the inferior border of the obturator foramen by crossing the obturator membrane, before reaching the middle plane of the perineum after having crossed the obturator internus muscle. The tape passes above the internal pudendal pedicle and then under the levator ani muscle, under the tendinous arch of the pelvic fascia and continues in the middle third of the urethrovaginal septum. It avoids femoral and obturator vessels in the thigh and pudendal vessels in the perineum. CONCLUSION: The anatomical course of transobturator tape shows that the anatomical structures crossed by the tape are muscle and fascia and, when the technique is performed correctly, no major neurovascular structures are in contact with the tape.