**9. Infection**

248 Urinary Incontinence

lesion of the internal pudendal artery. The complication was resolved with embolization of the artery guided with angiography, the treatment was successful. Jabureck et al (2011) documented that retropubic access surgery has a high lesion incidence of paraurethral,

Kuuva and Nilsson (2002) reported a nerve lesion 0.7/1000 with the placement of TVT.

Abouassaly et al (2004) reported a pelvic hematoma in 4 (1.9%) patients with TVT (4/421), Andonian et al (2005) reported a single case of an infected pelvic hematoma in the SPARC group and none in the TVT group. Pushky et al (2011) found that the formation of a hematoma is more frequent with TVT than with TVT-O (9.1% vs. 1.5%; p=0.001). Flock et al (2011) reported successful treatment of hematomas with retziusscopy in patients with TVT, of 685 patients, only 28 (4.1%) had a symptomatic hematoma in the Retzius space and in only 10 cases (1.5%) the volume exceeded 250 ml (range of 250-1000ml), the first case was resolved through laparotomy but the other cases were resolved successfully with a drainage through a retziusopy; this is a minimally invasive procedure. Latthe et al (2010) in a systematic review of 12 papers observed that the formation of hematomas is lower with the TOT procedure compared with the TVT with an OR of 0.06 (IC 95% 0.01-0.30). When Alvárez-Bandrés et al (2010) compared TVT –secur and Miniarc; they reported one case of hematoma of the obturator fossa (0.64%) in the Miniarc group, which resolved

Abouassaly et al (2004) reported urinary retention (>24 hours later) in 47 patients (19.7%). Of the 47 patients, retention was present in only 32 less than 48 hours later, which were managed with clean intermittent catheterization, the remaining 15 patients also had clean intermittent catheterization for several days and only one patient had catheterization for 22 days. In order to resolve retention in 7 patients, the mesh had to be released and in 3 patients the mesh had to be cut. Kristensen et al (2010) reported difficulty in voiding in 56% and 16.6% had urinary retention, 34.3% of the patients had catheterization and 8% needed continuous catheterization. They conclude that patients who had voiding dysfunction prior to surgery have an OR of 1.80 to present urinary retention post surgically. Lee et al (2010) reported that 10 patients with TVT surgery, (7.1%) had urinary retention after surgery; patients were treated with clean intermittent catheterization less than 1 week, 10 patients (7.1%) needed continuous catheterization and in 2 patients the TVT mesh had to be cut. George et al (2010) reported voiding difficulty with a follow up of 2 years; in the TVT group 9.3% it lasted less than one week and in 2.6% it lasted more than one week. In the TOT group, the voiding dysfunction was 4.1% less than 1 week and 1.4% more than 1 week. Bladder perforation has a higher incidence in the TVT group. Revicky et al (2011) reported urinary retention in 9% (31/342). Sun and Tsai (2011) reported a voiding dysfunction

bladder and paravesical plexus vessels and even external iliac vessels.

**7.1 Immediate post-surgical complications** 

**7. Nerve lesion** 

**7.1.1 Hematomas** 

spontaneously.

**8. Voiding disorders** 

Abouassaly et al (2004) reported infection of the supra pubic wound in one patient (0.4%). Kristensen et al (2010) reported infection of the urinary tract in 3.1%.

Flam et al (2009) had a patient with necrotizing fasciitis after placement of the TVT-O; they performed extensive debridement of the affected site, a colostomy, antibiotic therapy and 8 sessions of hyperbaric oxygen. Fig. 1

Fig. 1. 65-year-old with urinary incontinence, underwent a multifilament transobturator sling. At 14 months follow up, she experienced severe pelvic pain and vaginal discharge. Clinical examination revealed hyperthermia to 400C, sling exposure at right vaginal sulcus and severe cellulitis in the genital-crural fold: Classification: 3C T4 S 2 and 6C T4 S3

Lee et al(2011) in four of the five patients presented with symptom of chronic vaginal discharge and these patients have a chronic infection forming a sinus tract into the vagina or other viscus, causing symptoms years after its mesh placement.

Surgical Complications with Synthetic Materials 251

Abouassaly et al (2004) reported one patient with mesh erosion intravaginally (0.4%) (1/241); Andonian et al (2005) reported a single case of erosion in the SPARC group (1/41) and none in the TVT group (0/43). During the first year of follow up Rajendra et al (2011) reported vaginal erosion in 2.4 % (10/419); Ortega et al (2009) reported 1 case of erosion/extrusion of the mesh toward the urethra, the mesh was resected transvaginally with a good outcome. Wijffels et al (2009) reported 3 patients with urethral erosion/extrusion, treated by resection of the mesh endoscopically; Matsumura et al (2010) reported that after 2 years of surgery a 72 year old patient had an erosion/extrusion of the mesh in the urethra and a stone in the same site; management was done endoscopically with resection of the mesh and the stone was treated with lithotripsy with a good response.

Latthe et al (2010) in a systematic review reported that the mesh erosion of TVT-O has an OR 0.77 (IC 95% 0.22-2.72), while TOT and TVT have an almost similar OR 1.11 (IC 95%

Fig. 2. A 47-years-old woman underwent a transobturator tape for USI. At 5 months followup, she reported vaginal discharge. Clinically she was febrile at 380C with a large sling

When Alvárez-Bandrés et al (2010) compared TVT-secur and Miniarc they reported vaginal erosion in 8 patients (5%); 4 patients required removal and closure of the vaginal wall, 2 were treated with local estrogen therapy in the vagina and 2 were asymptomatic and did

Lo and Nusse (2010) reported a rare case of erosion over the bladder dome with formation of a stone 11 years after insertion of the TVT. Diagnosis was made with cystoscopy after the patient referred symptoms of the lower urinary tract for 5 months. A cysto-lithotripsy was performed observing a small filament of the mesh that was removed. A control cystoscopy was made

extrusion as depicted. Classification: 3C T3 S1

not require any treatment.

**12.1 Mesh extrusion** 

0.54-2.28) Fig. 2
