**3. Classification**

242 Urinary Incontinence

of this procedure include bladder neck obstruction and chronic cystitis. Subsequently, his

Vervigni and Natale (2001) described the three most important components for the use of a mesh in urological reconstructive surgery: the pore size, the type of fiber and its inflexibility. The pore size and the type of fiber may be used to classify mesh in 4 types: Mesh type 1, such as prolene, which is very soft (Ethicon, Endosurgery Inc, Summerville) and Marlex, having a long pore (>75μg) and usually made of polypropylene. This pore size allows macrophages to cross over and there is growth of fibroblasts (fibroplasias), as well as blood vessels (angiogenesis), and collagen deposits; White (1988) reported that because of these features, the mesh leads to changes to prevent infections and fibrous connective tissue grows around the tissue. Type II mesh such as Gore-tex (WL Gore & Associates Inc; Flagstaff, AZ) has a pore size under 10 μg in each one of its three dimensions (micropore). Mesh type III, such as Mersilene, is a macropore shaped naturally, but with micropore components that often include braided material and one/or multiple filaments. Mesh type IV has material with a pore size under a micron, and it is not used as a sling for urinary incontinence surgical procedures. (Table 1). Another important property is fiber composition: polypropylene mesh is made of monofilament and there are others made of multiple filaments which are commonly used. Multiple filament mesh often has a hole less than 10 μg wide, allowing small bacteria to infiltrate and proliferate. In theory, this small hole does not allow macrophages (16 to 20 μg) or white cells (9 a 15 μg) to pass through to kill bacteria, resulting in potential risk of infections. Flexibility or inflexibility of the mesh is another important feature. Prolene has a pore size twice as big as Marlex (1500 μg vs. 600 μg) and is much more flexible. Considering all of these properties, theoretically, prolene

patients had problems of erosion, infection and fistula formation

may have the lowest rate of erosion on the vagina and adjacent organs.

Table 1. Classification of Mesh Types

injuries were also documented.

Type Fiber Pore Size I Monofilament Macro(>75μm) II Multifilament Micro(<75μm) III Multifilament Variable IV Monofilament Submicro

Ulmsten et al (1996) were the first to use a tension-free polypropylene mesh (TVT) to repair female stress urinary incontinence. They used a prolene mesh to support the mid urethra. The procedure needs to be performed with cystoscopy. This procedure was designed to avoid excessive tension and the kit is adjusted according to a cough test. The authors do not report any complication during surgery and they conclude that the procedure has a good success rate. This surgical procedure was known worldwide and surgeons started to use it, however some time later, complications were reported in publications. Primicero et al (1999) used the device in 24 patients, reporting a case of a patient with perforation of the external iliac vein and needing surgical repair. Brink (2000) reported a case of intestinal injury. Already in the year 2005 Atherton and Stanton reported that the bladder perforation rate with this kit has a 4.4% incidence in up to 71% of cases, but these were not the only complications. Delorme et al (2204) was the first to use the approach through the obturator hole. In this procedure it is not necessary to use cytoscopy. But some time later, urinary tract Haylen et al (2011) in The Standardization and Terminology Committees of the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and the joint IUGA/ICS working group on Complications Terminology seek to provide a terminology and a standardized classification for those complications arising directly from the insertion of prostheses and graft in female pelvic floor surgery. A significant increase in the use of an ever widening array of prostheses and graft has occurred in female pelvic floor surgery over the last 30 years. Terminology involved in the classification (Table 2), Classification of complications related directly to the insertion of prosthesis (Table 3) and Grades of pain (Table 4)


Table 2. Terminology involved in the Classification.

Surgical Complications with Synthetic Materials 245

To specify the presence of pain (by the patient only, not the partner) as part or all of the

Jeffry et al (2001) reported that the bladder lesion rate due to perforation, increased in patients who had a prior anti-incontinence surgical procedure, this is due to the retropubic scarring process, and they also observed that the bladder perforation site is greater on the

Is a bladder lesion never observed during cystoscopy? Not really. Buchsbaum et al in (2004) reported that when they discarded the presence of bladder lesion after a cystoscopy, they found fluid leak through the incision or through the trocar path. Therefore, it is important to perform an appropriate bladder distension in order to separate the bladder folds and discard or confirm this complication appropriately. If necessary, methylene blue or indigo

What is the anatomical relationship between vascular anatomy and placement of trocars in the insertion of a TVT? Muir et al (2003) did an anatomical dissection in cadavers and found that the TVT trocar goes through at an average distance of 4.9 cm from the external iliac artery and 3.2 cm from the obturator vessels, therefore, when the trocar goes in deviated laterally, it can cause an injury to the external iliac artery or vein. An inadequate technique

Is the patient's position as well as position of the legs important to avoid complications? Yes. Whiteside et al (2004) reported the anatomy of the neurovascular bundle in relation to the obturator fossa when the TOT is placed; the trocar goes through at a 1.1 ± 0.4 cm average distance from the medial branch of the obturator vessels and the average distance to the obturator nerve is 2.5 ± 0.7 cm. Hubka et al (2010) reported in a study of 14 embalmed bodies with poor position of the legs (group 1), 5 fresh frozen bodies with poor leg position (group 2) and 5 fresh frozen bodies with the proper leg position (group 3). After dissection, they measured the rami of the obturator nerve; in group 1, the average distance of the anterior ramus of the obturator nerve was at 8.4 mm (left) and at 8.9 mm (right). In group 2 the average was 5 mm (left) and at 8 mm (right) and the posterior ramus of the obturator nerve was at 5 mm (left) and 8 mm (right) respectively. In group 3, the average distance of the anterior ramus of the obturator nerve was 24mm (left) and 23 mm (right). Therefore, the correct position of the patient and of the legs ensures proper placement of the TVT-O.

Several factors have been proposed for complications with these kits: broad dissection with devascularization of the vaginal tissue, estrogen deficiency, excess tension, and presence of subclinical or overt infection before surgery, poor placement of the patient's legs during

surgery, poor knowledge of the surgical technique to place the kits and smoking.

abnormal findings and the grade in terms of presence and severity of symptoms

b Provoked pain only (during vaginal examination)

Table 4. Grades of pain: Sub classification of complication category

a Asymptomatic or no pain

e Spontaneous pain.

opposite side of the surgeon's dominating hand.

when the trocar is inserted can cause severe complications.

**4. Pathophysiology** 

carmine can be used.

c Pain during sexual intercourse d Pain during physical activities


Table 3. A Classification of complications related directly to the insertion of prosthesis (meshes, implants, tapes) or graft in female pelvic floor surgery.


Table 4. Grades of pain: Sub classification of complication category
