**18.3 Treatment of post-operative complications**

Abouassaly et al (2004) recommend in patients with voiding dysfunctions, the use of clean intermittent catheterization and if it has to be for a longer period of time, the mesh must be released, and in patients who continue with voiding disorders the mesh must be cut.

Abouassaly et al (2004) reported that when an infectious process arises, a culture must be performed and antibiotics should be prescribed depending on the sensitivity obtained; and as reported by Flam et al (2009) hyperbaric oxygen can be used to improve oxygenation of the tissue involved with excellent results. Abouassaly et al (2004) recommend for intravaginal mesh erosion, partial resection of the meshes and repair of the vaginal epithelium if the patient refers symptoms if not, she can just be observed as reported by

Surgical Complications with Synthetic Materials 257

necessary to repair the injury, with an intestinal resection and/or colostomy depending on

Rigaud et al (2010) said that for the treatment of pelvic or perineal pain we can infiltrate local anesthesia throughout the mesh or in the nerves involved, thus achieving temporary clinical improvement. However, although there was improvement in 2 of their 3 patients,

Mendoca et al(2011) describe a minimally invasive trans-urethral approach for the urethral erosion under local anaesthesia. They present some "tricks of the trade" on retrieving the

Khong and Lam (2011) in nine patients with synthetic mesh erosion when failed to respond to conservative measures were managed surgically with Surgisis. The size erosion ranged from 1 to 4 cm in diameter. The Surgisis may prove to be a useful option in the treatment of

Whenever a surgical procedure involving the use of a mesh for urinary incontinence (any sort of mesh found in the market), the patient and her family must be informed about risks and complications. It is also important to have an informed consent for the patient stating the incidence of each of the complications pertaining to the specific kit used. Surgeons should follow patients at long term, since many complications occur after a long time, and they should be prepared to act quickly and effectively to solve the complication that has arisen. The use of new technology has improved the success rate of the surgical procedures for urinary incontinence, but clinically and legally, surgeons are the ones that should determine the use of these new devices and not the representatives of the commercial houses. We suggest that all suburethral slings are not created equal and that clinical adoption of new technology should follow clinical trials demonstrating efficacy, safety and

Abdel-Fattah M, Ramsay I, Pringle S, Hardwick C, Ali H, et al(2010). Randomised

Abouassaly R, Steinberg JR, Lemieux M, Marois C, Gilchrist LI, et al. (2004) Complications

Alvarez-Bandrés S, Hualde-Alfaro A, Jiménez-Calvo J, Cebrián-Lostal JL, Jiménez-Parra JD,

Andonian S, Chen T, St Denis B and Corcos J. (2005). Randomized clinical trial comparing

outcomes from the E-TOT study. *BJOG.*;117(7):870-8.

system. Actas Urol Esp. 34(10):893-7.

prospective single-blinded study comparing 'inside-out' versus 'outside-in' transobturator tapes in the management of urodynamic stress incontinence: 1-year

of tension-free vaginal tape surgery: a multi-institutional review. *BJU Int*.

et al. (2010).Complications of female urinary incontinence surgery with mini-sling

suprapubic arc (SPARC) and tension-free vaginal tape (TVT): one year results. *Eur* 

tape trans-urethrally while maximizing the length of tape removed.

the lesion found.

the mesh had to be removed.

large vaginal mesh defects.

**19. Conclusion** 

long-term outcomes.

94(1):110-3.

*Urol* 47(4):537-41.

**20. References** 

Alvárez-Bandrés et al (2010). Giri et al (2007) recommend a primary closure of the vaginal mucosa with a single line of a polyglactine 910, 2/0 suture avoiding inversion of the mucosa, when there is extrusion of the TVT mesh toward the vagina.

Rouprêt et al (2010) reported surgical resection of the mesh through laparoscopy, in 38 women with complications like: bladder erosion, vaginal extrusion, bladder obstruction and groin pain. Resection was complete in all patients through laparoscopy; with an operating time of 110 minutes (range of 50 to 240 minutes) all patients reported a decrease in symptoms in a follow up period of 37.9 months (range 2-80 months). However, the recurrence rate of incontinence was 65.7% (25 patients). Laparoscopic resection of the TVT is safe and technically possible and solves patient's symptoms if we have the necessary instruments as well as trained personnel since it is a minimally invasive treatment alternative. In patients with de novo urgency, the use of anticholinergics is necessary to improve the patient's quality of life and in patients who report pelvic or perineal pain we can prescribe NSAID's.

When there is mesh extrusion and there is no satisfactory response to primary management such as the use of antibiotics or application of local estrogen in the organ extruded; the appropriate management is to remove the mesh. Fig 3. Removal of the mesh has been performed vaginally, via the urethra or the ureter through cystoscopy or laparoscopy with a good success rate and it is a minimally invasive procedure.

Fig. 3. The appropriated management is to remove the mesh when there is no satisfactory response to primary management.

Lo and Nusse (2010) recommend that in patients who have had a TVT or any other kit inserted to treat urinary incontinence and who show irritation symptoms of the lower urinary tract, a cystoscopy must be done to discard the presence of the mesh in the vagina, the urethra or in any other organ. If an intestinal injury is suspected, additional imaging test should be performed to document the injury and an exploratory laparotomy will be necessary to repair the injury, with an intestinal resection and/or colostomy depending on the lesion found.

Rigaud et al (2010) said that for the treatment of pelvic or perineal pain we can infiltrate local anesthesia throughout the mesh or in the nerves involved, thus achieving temporary clinical improvement. However, although there was improvement in 2 of their 3 patients, the mesh had to be removed.

Mendoca et al(2011) describe a minimally invasive trans-urethral approach for the urethral erosion under local anaesthesia. They present some "tricks of the trade" on retrieving the tape trans-urethrally while maximizing the length of tape removed.

Khong and Lam (2011) in nine patients with synthetic mesh erosion when failed to respond to conservative measures were managed surgically with Surgisis. The size erosion ranged from 1 to 4 cm in diameter. The Surgisis may prove to be a useful option in the treatment of large vaginal mesh defects.

#### **19. Conclusion**

256 Urinary Incontinence

Alvárez-Bandrés et al (2010). Giri et al (2007) recommend a primary closure of the vaginal mucosa with a single line of a polyglactine 910, 2/0 suture avoiding inversion of the

Rouprêt et al (2010) reported surgical resection of the mesh through laparoscopy, in 38 women with complications like: bladder erosion, vaginal extrusion, bladder obstruction and groin pain. Resection was complete in all patients through laparoscopy; with an operating time of 110 minutes (range of 50 to 240 minutes) all patients reported a decrease in symptoms in a follow up period of 37.9 months (range 2-80 months). However, the recurrence rate of incontinence was 65.7% (25 patients). Laparoscopic resection of the TVT is safe and technically possible and solves patient's symptoms if we have the necessary instruments as well as trained personnel since it is a minimally invasive treatment alternative. In patients with de novo urgency, the use of anticholinergics is necessary to improve the patient's quality of life and in patients who report pelvic or perineal pain we

When there is mesh extrusion and there is no satisfactory response to primary management such as the use of antibiotics or application of local estrogen in the organ extruded; the appropriate management is to remove the mesh. Fig 3. Removal of the mesh has been performed vaginally, via the urethra or the ureter through cystoscopy or laparoscopy with a

Fig. 3. The appropriated management is to remove the mesh when there is no satisfactory

Lo and Nusse (2010) recommend that in patients who have had a TVT or any other kit inserted to treat urinary incontinence and who show irritation symptoms of the lower urinary tract, a cystoscopy must be done to discard the presence of the mesh in the vagina, the urethra or in any other organ. If an intestinal injury is suspected, additional imaging test should be performed to document the injury and an exploratory laparotomy will be

mucosa, when there is extrusion of the TVT mesh toward the vagina.

good success rate and it is a minimally invasive procedure.

can prescribe NSAID's.

response to primary management.

Whenever a surgical procedure involving the use of a mesh for urinary incontinence (any sort of mesh found in the market), the patient and her family must be informed about risks and complications. It is also important to have an informed consent for the patient stating the incidence of each of the complications pertaining to the specific kit used. Surgeons should follow patients at long term, since many complications occur after a long time, and they should be prepared to act quickly and effectively to solve the complication that has arisen. The use of new technology has improved the success rate of the surgical procedures for urinary incontinence, but clinically and legally, surgeons are the ones that should determine the use of these new devices and not the representatives of the commercial houses. We suggest that all suburethral slings are not created equal and that clinical adoption of new technology should follow clinical trials demonstrating efficacy, safety and long-term outcomes.
