**18. Diagnosis**

All patients who have had any of the anti-incontinence kits available in the market placed through the following procedures: retropubic, transobturator, outside-in or inside-out, or any minimally invasive kit, should be followed up long term since complications have been observed up to 11 years after insertion.

For intra-operative complications it is necessary to observe the patient's vitals: heart rate, blood pressure, oxygen saturation, state of awareness, so that if a disturbance is observed in any of these parameters, any necessary additional tests can be performed; like clinical labs to diagnose a vascular complication. A cystoscopy should be performed to assess the entire bladder with proper distention (250 cc minimum of physiologic solution) and with the proper instrument like a 700 lens cystoscope in order to check the bladder dome and lateral bladder walls; and for the urethra a 00 or 300 lens. In the event of doubt we can use methylene blue or indigo carmine to identify any damage that may be overlooked. Hematomas are identified according to the amount or size of the hematoma, it can go from mild pain, ecchimosis or hemorrhage through the puncture sites; this can be confirmed with imaging tests (ultrasound, axial CAT scan, MRI) depending on the patient's clinical status.

For post-operative complications: signs and symptoms of a patient who refers voiding disorders, residual urine should be measured using a clean bladder catheter or with translabial or suprapubic ultrasound in order to measure urine. De novo urgency can be documented by asking the patient directly and with a multichannel Urodynamic or Video-Urodynamic test, depending on the discomfort reported by the patient. During the patient's visit to the office, the vagina and urethra must be checked to discard any extrusion complications. A cystoscopy, a urethroscopy or an additional test must be performed depending on the symptoms reported by the patient. If the patient shows any irritation symptoms in the lower urinary tract or in the bowel, hematuria, dispareunia, discomfort reported by the spouse, voiding disorders, pain, recurring infections, palpation of the mesh or recurring urinary incontinence, the integrity of the urinary tract and adjacent organs must be documented. If a patient has an intestinal injury, they will refer abdominal pain, signs of peritoneal irritation and sometimes leak of fecal matter through the incision of the kit used.

Rigaud et al (2010) said that when the patient refers perineal pain or chronic pelvic pain, immediately or shortly after insertion of a TVT or TOT Kit, this is probably associated directly or indirectly to a nerve injury (obturator nerve or pudendal nerve); diagnosis is made with the history that pain started after insertion of the kit and it can be confirmed with infiltration of local anesthesia through the mesh. This complication may be underestimated.

### **18.1 Treatment**

254 Urinary Incontinence

Abdel-Fattah et al (2010) did a randomized report of 341 patients who had an outside-in transobturator (TOT-ARIS) and an inside-out (TVT-O). The risk factors for failure in the insertion of these meshes are: prior incontinence surgery (OR 1.41; 95% CI 1.18, 1.91; P = 0.029), preoperative urgency urinary incontinence (OR 1.78; 95% CI 1.21, 3.91, P = 0.048)

Revicky et al (2011) evaluated the following risk factors to predict failure of the procedure: body mass index (BMI), age, type of analgesia, concomitant prolapse repair or prior surgery and obesity. These factors were not related to bladder injury or to urinary retention. Liu et al (2011) reported that obesity was not a risk factor for surgical failure just like Revicky

When Pushkar et al (2011) evaluated risk factors like age, body mass index and parity; there

All patients who have had any of the anti-incontinence kits available in the market placed through the following procedures: retropubic, transobturator, outside-in or inside-out, or any minimally invasive kit, should be followed up long term since complications have been

For intra-operative complications it is necessary to observe the patient's vitals: heart rate, blood pressure, oxygen saturation, state of awareness, so that if a disturbance is observed in any of these parameters, any necessary additional tests can be performed; like clinical labs to diagnose a vascular complication. A cystoscopy should be performed to assess the entire bladder with proper distention (250 cc minimum of physiologic solution) and with the proper instrument like a 700 lens cystoscope in order to check the bladder dome and lateral bladder walls; and for the urethra a 00 or 300 lens. In the event of doubt we can use methylene blue or indigo carmine to identify any damage that may be overlooked. Hematomas are identified according to the amount or size of the hematoma, it can go from mild pain, ecchimosis or hemorrhage through the puncture sites; this can be confirmed with imaging tests (ultrasound, axial CAT scan, MRI) depending on the patient's clinical status. For post-operative complications: signs and symptoms of a patient who refers voiding disorders, residual urine should be measured using a clean bladder catheter or with translabial or suprapubic ultrasound in order to measure urine. De novo urgency can be documented by asking the patient directly and with a multichannel Urodynamic or Video-Urodynamic test, depending on the discomfort reported by the patient. During the patient's visit to the office, the vagina and urethra must be checked to discard any extrusion complications. A cystoscopy, a urethroscopy or an additional test must be performed depending on the symptoms reported by the patient. If the patient shows any irritation symptoms in the lower urinary tract or in the bowel, hematuria, dispareunia, discomfort reported by the spouse, voiding disorders, pain, recurring infections, palpation of the mesh or recurring urinary incontinence, the integrity of the urinary tract and adjacent organs must be documented. If a patient has an intestinal injury, they will refer abdominal pain, signs of peritoneal irritation and sometimes leak of fecal matter through the incision of the kit used.

**17. Risk factors for surgical failure** 

observed up to 11 years after insertion.

reported in his review.

**18. Diagnosis** 

during the first year of follow up of these surgeries.

was no correlation with the complications of TVT and TVT-O.

Treatment of complications with these kits is still not standardized and it is something we will have to work on. When complications are severe, a multidisciplinary team is necessary to provide the best treatment and obtain favorable results for the patient.
