**12. Pain and suprapubic discomfort**

Abouassaly et al (2004) reported persisting suprapubic discomfort in 18 (7.5%) (18/241 patients). Rajendra et al (2011) after following up 419 patients for 3 years reported persistent pain in 15 patients (3.6%). Ross et al (2009) reported 199 patients, 105 of these had a TVT inserted and 94 patients had a TVT-O; they documented in the vaginal examination that the mesh was palpable in 68 (80%) in the TVT-O group and in 24 (27%) of the TVT group ( RR 0.22, CI 95% 0.13-0.37, P<.001); many women are also experiencing groin pain during vaginal palpation, 13 patients (15%) in the TVT-O group and 5 patients (6%) in the TVT group.

Latthe et al (2010) did a systematic review reporting that groin and/or thigh pain with the TVT-O procedure has an OR of 8.05 (IC 95% 3.78-17.16).

When Alvárez-Bandrés et al (2010) compared TVT-secur and Miniarc; the Miniarc group reported 4 (2.5%) patients with groin pain who were treated successfully with NSAID's.

### **12.1 Mesh extrusion**

250 Urinary Incontinence

Abouassaly et al (2004) reported de novo urgency in 36 patients (15%), Lleberia-Juanós et al (2011) determined the incidence of de novo urgency with VT (in 243 patients) and with TVT-O (123 patients) evaluating them at 1, 6, 12 and 36 months after surgery. De novo urgency occurs in 13.4% of patients at 6 months, in 19.3 at 12 months and in 22.1% at 36 months. De novo urgency was more frequent in the TVT group than in the TVT-O group at 12 months (22.2% vs. 11.2%, P=0.025) and at 24 months (24.8% vs. 12.3%, P=0.033). Lee et al (2010) after 6 years of observation reported that de novo urgency was present in 28% (30/107) and de novo overactive bladder with incontinence was present in 27.1% (29/107) of patients. Sun and Tsai (2011) reported a frequency of de novo urgency of 2.7% with MONARC (2/73). Sabadell et al (2011) reported that 23 patients failed to TOT and a TVT was placed in a second surgery; de novo urgency occurs in 5 cases (21.7%) and it is treated with oral

Rajendra et al (2011) reported after a 3 year follow up, that 11 patients with TVT-O (2.6%) (11/419) were readmitted since 10 patients had voiding dysfunction, in 6 patients it was necessary to remove or cut the tape. Reich et al (2011) reported it in 108 patients in a follow up period of 102 months (range of 85-124). They did not find adverse effects of the mesh; 90% of these patients presented urgency incontinence and were dissatisfied with the surgical procedure. The same group studied 478 with TVT and voiding dysfunction, documenting it by measuring residual volume pre and post surgery; they reported micturition dysfunction in the first 2 weeks in 4 patients (0.8%), 7.1% had a residual volume of 50-100 ml at 3 months of surgery and 2.6% had a residual urine volume of over 100 ml. Therefore, a total of 93% of patients did not show bladder voiding disorders after a follow up of 12 to 74 months, which was documented through translabial ultrasound. Alvárez-Bandrés et al (2010) reported that the Miniarc group had urethral obstruction and thus the

Abouassaly et al (2004) reported persisting suprapubic discomfort in 18 (7.5%) (18/241 patients). Rajendra et al (2011) after following up 419 patients for 3 years reported persistent pain in 15 patients (3.6%). Ross et al (2009) reported 199 patients, 105 of these had a TVT inserted and 94 patients had a TVT-O; they documented in the vaginal examination that the mesh was palpable in 68 (80%) in the TVT-O group and in 24 (27%) of the TVT group ( RR 0.22, CI 95% 0.13-0.37, P<.001); many women are also experiencing groin pain during vaginal palpation, 13 patients (15%) in the TVT-O group and 5 patients (6%) in the TVT

Latthe et al (2010) did a systematic review reporting that groin and/or thigh pain with the

When Alvárez-Bandrés et al (2010) compared TVT-secur and Miniarc; the Miniarc group reported 4 (2.5%) patients with groin pain who were treated successfully with NSAID's.

**10. Late complications 10.1 De novo urgency** 

**11. Voiding disorders** 

mesh had to be cut.

group.

anticholinergics with a good clinical response.

**12. Pain and suprapubic discomfort** 

TVT-O procedure has an OR of 8.05 (IC 95% 3.78-17.16).

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% 0.54-2.28) Fig. 2

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 extrusion as depicted. Classification: 3C T3 S1

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 not require any treatment.

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

Surgical Complications with Synthetic Materials 253

(2002); Leboeuf et al (2003) and Castillo et al (2004). Leboeuf et al (2004) did a vaginal hysterectomy in a 73 year old patient due to genital prolapse followed by insertion of a TVT, during the post-op period she presented abdominal distension, and in an axial CAT scan they observed bowel distention and the bowel lesion site; they did an exploratory laparotomy where they found perforation of the mesentery without no other lesion, the

Phillips et al (2009) reported a small size, thin patient with clinical signs of intestinal obstruction 3 years after the insertion of a TVT; she underwent an exploratory laparotomy where they found that the TVT mesh went through the peritoneum and was attached to the

Geis and Dietl (2002) reported an ilioinguinal nerve lesion after insertion of a TVT, this due to the closeness of the nerve to the sites where the suprapubic incision was made. Rigaud et al (2010) said that pelvic or perineal pain may be a consequence of the obturator nerve or

Lau et al (2010) evaluated the impact of TVT-O insertion on sexual function in 56 women; they were evaluated through short questionnaires PISQ-12, UDI-16 and the IIQ7 before and 6 months after surgery. Their conclusion was that women perceived the surgery was

Jain et al (2011) did a systematic review of TVT and TOT in the treatment of Mixed Urinary Incontinence (MUI). The subjective cure rate in 7 prospective trials was 56.4% (IC 95% 45.7- 69.6%) in a follow up period of 34.9±22.9 months. The cure rate for stress urinary incontinence varied from 85% to 97% in a follow up period of 6 to 31 months. TVT and TOT have a similar cure in mixed urinary incontinence. Madhuvrata et al (2011) in a systematic review and meta-analysis of the mini-sling (SIMS) compared the retropubic procedure: TVT (9 studies were included) and TVT-O (7 studies were included). The objective short term cure rate (6-12 months) was greater in urethral sling procedures than in mini-slings (SIMS) with a RR 1.20 (IC 95% 1.01-1.43) and RR 1.18 (IC 95% 1.04-1.34); a second surgery was necessary in the SIMS group with a RR 0.15 (IC 95% 0.05-0.42). Novara et al (2010) in a systematic review and meta-analysis of 39 papers reported that patients who had a suburethral mesh inserted the objective cure rate had an OR: 0.38 (IC95% 0.25-0.57; p=<0.0001) compared to the patients who had a Burch colpo-suspension procedure, although they had a high bladder perforation risk with an OR of 4.94 (IC 95% 2.09-11.68; p= 0.00003). Patil (2011) in a total of 12977 surgeries performed in 68 centers in the United Kingdom, 313 patients (2.4%) failed to sub-urethral slings. Chen et al (2011) in 30 patients followed up 1 year, who had a TVT-secur inserted, the success rate decreased significantly from 83.3% one month

perforation was repaired without complications.

**14. Nerve lesion** 

**15. Sexual function** 

**16. Success and failure** 

distal ileus; they did a resection and a primary anastomosis.

pudendal nerve lesion, a clinical sign that is underestimated.

successful but there was no improvement in sexual function.

after surgery to 60.0% one year after the procedure.

after one year showing recurrence of a stone in the same site of the previous surgery; surgery was performed in the office since the patient refused major surgery. Siegel (2006) reported one case of urethral necrosis and a urethra-vaginal fistula in a 64 year old woman, who needed 3 surgeries; initially TVT mesh fragments were removed and adjacent tissue needed debridement. A urethroplasty was performed as a second surgical procedure and in the third surgery a coaptation with an occlusive sling was made to repair the continence.

E Kobashi's (2009) reviewed the different materials and reported the rate of extrusion of these. Table 5.


Table 5. Synthetic mesh types, Characteristics and Associated Vaginal Extrusion rates.

Miraliakbari and Tse (2011) reported the first case of ureteral erosion in a 78 year old woman, the erosion was located in the distal third of the ureter, and the patient was treated successfully.

Rouprêt et al (2010) reported resection of the mesh via laparoscopy in 38 women with bladder erosion, vaginal extrusion, bladder obstruction and groin pain. The resection was complete with an operating time of 110 minutes (50 to 240 minute range) all patients reported a decrease in symptoms in a follow up period of 37.9 months (2-80 months range). However, the incontinence recurrence rate is 65.7% (25 patients). Laparoscopic resection of the TVT is safe and technically possible and solves patient's symptoms.

Novara et al (2010) did a systematic review of pubovaginal sling; retropubic tape (RT) and transobturator tape (TOT) the subjective cure rate is similar among those procedures. Patients who have a TOT inserted have less risk of bladder or vaginal perforation (OR: 2.5 IC: 1.75-3.57; p<0.00001); less risk of hematoma (OR: 2.62; CI: 1.35-5.08; p=0.005) and less risk of urinary tract injury (OR: 1.35; CI: 1.05-1.72; p=0.02). This meta-analysis showed similar results between TVT-O and Monarc. The use of a retropubic tape had a higher objective rate than TOT, but the subjective cure is similar for both.

Mendoca et al (2011) report two cases with late urethral erosion with transobturator suburethral mesh (Obtape) the first one diagnosed 1 year after the surgery and the second one, a very late complication, occurring 4 years after the placement of the sling.
