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Bladder injury during transobturator sling
CASE REPORT
BLADDER INJURY DURING TRANSOBTURATOR SLING ¨ ZEL, CARL KLUTKE, CHARLES BALLARD, STEVEN MINAGLIA, BEGU¨M O
AND
JOHN KLUTKE
ABSTRACT The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure. UROLOGY 64: 376.e1–376.e2, 2004. © 2004 Elsevier Inc.
T
he transobturator sling for surgical treatment of female genuine stress urinary incontinence was introduced by Delorme1 in 2001. One of the potential advantages of this technique is that it avoids the risk of bladder injuries, frequently observed during retropubic needle passage. Both anatomic studies and a single case report to date, however, have demonstrated that bladder injuries may still occur with the use of this new transobturator approach.2 We describe 3 cases in which this complication occurred. CASE REPORTS PATIENT 1 A 49-year-old woman, 66 in. tall and weighing 229 lb, presented with bothersome stress urinary incontinence after vaginal hysterectomy and posterior colporrhaphy for symptomatic vaginal prolapse 4 years previously. Evaluation of her current complaint found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test with a Valsalva leak point pressure of 127 cm H2O and 150 mL of fluid in the bladder. She underwent a transobturator From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California; and Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Address for correspondence: Steven Minaglia, M.D., Los Angeles County Women’s and Children’s Hospital, 1240 North Mission Road, Room L1009, Los Angeles, CA 90033 Submitted: February 20, 2004, accepted (with revisions): April 7, 2004 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
tape procedure (Mentor, Santa Barbara, Calif) followed by posterior colporrhaphy under general endotracheal anesthesia. Intraoperatively, passage of the Emmett needle was difficult secondary to the patient’s habitus. The non-woven polypropylene mesh was inserted, as described by Delorme.1 Cystoscopy, performed routinely at our institution, revealed a right anterior lateral bladder perforation. With the bladder drained, the mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscope. The procedure was completed, and posterior colporrhaphy was performed. The patient was discharged the following day. Transurethral bladder drainage by Foley catheter was maintained for 7 days postoperatively. On postoperative day 7, the patient’s postvoid residual volume was 20 mL after voiding 250 mL spontaneously. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. PATIENT 2 A 50-year-old woman, 58 in. tall, weighing 133 lb, presented with bothersome stress urinary incontinence after vaginal hysterectomy and anterior and posterior colporrhaphy for symptomatic vaginal prolapse 2 years previously. Evaluation of her current complaint found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test starting at 200 mL H2O in her bladder. The maximal urethral closure pressure was 20 cm H2O. She underwent a transobturator tape procedure (Mentor) under local anesthesia. Intraoperatively, passage of 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.04.030 376.e1
the Emmett needle was uneventful. Cystoscopy revealed a right anterior lateral bladder perforation. With the bladder drained, the mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscopy. The patient was discharged home the same day. Transurethral bladder drainage by Foley catheter was maintained for 7 days postoperatively. On postoperative day 7, the patient’s postvoid residual volume was 30 mL after voiding 220 mL. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. PATIENT 3 A 62-year-old woman, 66 in. tall, weighing 140 lb, presented with bothersome stress urinary incontinence after hysterectomy several years previously and abdominal sacrocolpopexy 3 months previously. Evaluation found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test with a Valsalva leak point pressure of 99 cm H2O with 150 mL of fluid in the bladder. She underwent a transobturator tape procedure (Mentor) under local anesthesia. Intraoperatively, passage of the Emmett needle was accompanied by leakage of urine from the vaginal incision. Consequently, cystoscopy was performed and revealed a perforation at the bladder neck. The mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscopy. The patient was discharged home the same day. Transurethral bladder drainage by Foley catheter was maintained for 5 days postoperatively. On postoperative day 5, the patient voided without difficulty. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. COMMENT Bladder injury is the most common complication of retropubic placement of suburethral tensionfree vaginal tape for the treatment of female stress urinary incontinence, with an incidence of 2% to 11.5% reported in published studies.3– 6 In women with prior failed incontinence surgery, the incidence of bladder perforation with the tension-free vaginal tape procedure is as high as 19%.7 The transobturator approach, described by Delorme,1 minimizes retropubic needle passage. Dargent et al.8 reported no bladder perforations in 71 patients. Consequently, application of the transobturator approach without routine intraoperative cystoscopy can be considered.
376.e2
Bladder injury occurred in 3 of 61 patients who underwent the transobturator tape procedure at both institutions. At the University of Southern California, Los Angeles County Women’s and Children’s Hospital, we routinely perform cystoscopy during all anti-incontinence procedures. In the first patient, needle placement was difficult secondary to obesity. In the second patient, who had undergone surgery for prolapse repair 2 years previously, the procedure was performed without difficulty. In the third patient, prior surgery may have contributed to perforation of the bladder. In this case, cystoscopy was performed because of suspicion of bladder injury. Thus, early experience with the procedure, patient obesity, and prior surgery may all have contributed to bladder penetration, although we did not suspect this complication in the first 2 patients. Cystoscopy is safe and easy to perform. In our experience with 61 patients, it allowed us to identify two unsuspected bladder injuries, successfully reinsert the transobturator tape in all 3 cases, and determine appropriate postoperative management. Routine intraoperative cystoscopy is therefore recommended for the identification of bladder injuries during the transobturator sling procedure. As the transobturator sling procedure becomes widely practiced, additional studies will be needed to quantify its complications. REFERENCES 1. Delorme E: Transobturator urethral suspension: miniinvasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 11: 1306 –1313, 2001. 2. Hermieu JF, Messas A, Delmas V, et al: Bladder injury after TVT transobturator [in French]. Prog Urol 13: 115–117, 2003. 3. Meschia M, Pifarotti P, Bernasconi F, et al: Tension-free vaginal tape: analysis of outcomes and complications in 404 stress incontinent women. Int Urogynecol J Suppl 2: S24 –S27, 2003. 4. Tamussino KF, Hanzal E, Kolle D, et al: Tension-free vaginal tape operation: results of the Austrian registry. Obstet Gynecol 98: 732–736, 2001. 5. Soulie M, Cuvillier X, Benaissa A, et al: The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study. Eur Urol 39: 709 –715, 2001. 6. Olsson I, and Kroon UB: A three-year postoperative evaluation of tension-free vaginal tape. Gynecol Obstet Invest 48: 267–269, 1999. 7. Azam U, Frazer MI, Kozman EL, et al: The tension-free vaginal tape procedure in women with previous failed stress incontinence surgery. J Urol 166: 554 –556, 2001. 8. Dargent D, Bretones S, George P, et al: Insertion of a sub-urethral sling through the obturator membrane for treatment of female urinary incontinence [in French]. Gynecol Obstet Fertil 30: 576 –582, 2002.
UROLOGY 64 (2), 2004
BLADDER INJURY DURING TRANSOBTURATOR SLING ¨ ZEL, CARL KLUTKE, CHARLES BALLARD, STEVEN MINAGLIA, BEGU¨M O
AND
JOHN KLUTKE
ABSTRACT The new minimally invasive transobturator sling for surgical treatment of female genuine stress urinary incontinence is designed to reproduce the natural suspension of the urethral fascia while eliminating the need for retropubic needle passage. We report 3 cases of bladder perforation during the transobturator sling procedure. All injuries were identified intraoperatively by cystoscopy, and successful reinsertion of the mesh was accomplished. Transurethral bladder drainage with a Foley catheter was maintained for 5 to 7 days postoperatively. All 3 patients recovered uneventfully. Routine intraoperative cystoscopy is, therefore, recommended for the identification of bladder injuries during the transobturator sling procedure. UROLOGY 64: 376.e1–376.e2, 2004. © 2004 Elsevier Inc.
T
he transobturator sling for surgical treatment of female genuine stress urinary incontinence was introduced by Delorme1 in 2001. One of the potential advantages of this technique is that it avoids the risk of bladder injuries, frequently observed during retropubic needle passage. Both anatomic studies and a single case report to date, however, have demonstrated that bladder injuries may still occur with the use of this new transobturator approach.2 We describe 3 cases in which this complication occurred. CASE REPORTS PATIENT 1 A 49-year-old woman, 66 in. tall and weighing 229 lb, presented with bothersome stress urinary incontinence after vaginal hysterectomy and posterior colporrhaphy for symptomatic vaginal prolapse 4 years previously. Evaluation of her current complaint found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test with a Valsalva leak point pressure of 127 cm H2O and 150 mL of fluid in the bladder. She underwent a transobturator From the Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California; and Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri Address for correspondence: Steven Minaglia, M.D., Los Angeles County Women’s and Children’s Hospital, 1240 North Mission Road, Room L1009, Los Angeles, CA 90033 Submitted: February 20, 2004, accepted (with revisions): April 7, 2004 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED
tape procedure (Mentor, Santa Barbara, Calif) followed by posterior colporrhaphy under general endotracheal anesthesia. Intraoperatively, passage of the Emmett needle was difficult secondary to the patient’s habitus. The non-woven polypropylene mesh was inserted, as described by Delorme.1 Cystoscopy, performed routinely at our institution, revealed a right anterior lateral bladder perforation. With the bladder drained, the mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscope. The procedure was completed, and posterior colporrhaphy was performed. The patient was discharged the following day. Transurethral bladder drainage by Foley catheter was maintained for 7 days postoperatively. On postoperative day 7, the patient’s postvoid residual volume was 20 mL after voiding 250 mL spontaneously. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. PATIENT 2 A 50-year-old woman, 58 in. tall, weighing 133 lb, presented with bothersome stress urinary incontinence after vaginal hysterectomy and anterior and posterior colporrhaphy for symptomatic vaginal prolapse 2 years previously. Evaluation of her current complaint found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test starting at 200 mL H2O in her bladder. The maximal urethral closure pressure was 20 cm H2O. She underwent a transobturator tape procedure (Mentor) under local anesthesia. Intraoperatively, passage of 0090-4295/04/$30.00 doi:10.1016/j.urology.2004.04.030 376.e1
the Emmett needle was uneventful. Cystoscopy revealed a right anterior lateral bladder perforation. With the bladder drained, the mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscopy. The patient was discharged home the same day. Transurethral bladder drainage by Foley catheter was maintained for 7 days postoperatively. On postoperative day 7, the patient’s postvoid residual volume was 30 mL after voiding 220 mL. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. PATIENT 3 A 62-year-old woman, 66 in. tall, weighing 140 lb, presented with bothersome stress urinary incontinence after hysterectomy several years previously and abdominal sacrocolpopexy 3 months previously. Evaluation found a hypermobile urethra, stable cystometrography findings, and normal voiding. She had a positive cough stress test with a Valsalva leak point pressure of 99 cm H2O with 150 mL of fluid in the bladder. She underwent a transobturator tape procedure (Mentor) under local anesthesia. Intraoperatively, passage of the Emmett needle was accompanied by leakage of urine from the vaginal incision. Consequently, cystoscopy was performed and revealed a perforation at the bladder neck. The mesh was removed. A second insertion was performed and confirmed to be without complication by cystoscopy. The patient was discharged home the same day. Transurethral bladder drainage by Foley catheter was maintained for 5 days postoperatively. On postoperative day 5, the patient voided without difficulty. She recovered uneventfully and was seen 6 weeks postoperatively without complaints. COMMENT Bladder injury is the most common complication of retropubic placement of suburethral tensionfree vaginal tape for the treatment of female stress urinary incontinence, with an incidence of 2% to 11.5% reported in published studies.3– 6 In women with prior failed incontinence surgery, the incidence of bladder perforation with the tension-free vaginal tape procedure is as high as 19%.7 The transobturator approach, described by Delorme,1 minimizes retropubic needle passage. Dargent et al.8 reported no bladder perforations in 71 patients. Consequently, application of the transobturator approach without routine intraoperative cystoscopy can be considered.
376.e2
Bladder injury occurred in 3 of 61 patients who underwent the transobturator tape procedure at both institutions. At the University of Southern California, Los Angeles County Women’s and Children’s Hospital, we routinely perform cystoscopy during all anti-incontinence procedures. In the first patient, needle placement was difficult secondary to obesity. In the second patient, who had undergone surgery for prolapse repair 2 years previously, the procedure was performed without difficulty. In the third patient, prior surgery may have contributed to perforation of the bladder. In this case, cystoscopy was performed because of suspicion of bladder injury. Thus, early experience with the procedure, patient obesity, and prior surgery may all have contributed to bladder penetration, although we did not suspect this complication in the first 2 patients. Cystoscopy is safe and easy to perform. In our experience with 61 patients, it allowed us to identify two unsuspected bladder injuries, successfully reinsert the transobturator tape in all 3 cases, and determine appropriate postoperative management. Routine intraoperative cystoscopy is therefore recommended for the identification of bladder injuries during the transobturator sling procedure. As the transobturator sling procedure becomes widely practiced, additional studies will be needed to quantify its complications. REFERENCES 1. Delorme E: Transobturator urethral suspension: miniinvasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 11: 1306 –1313, 2001. 2. Hermieu JF, Messas A, Delmas V, et al: Bladder injury after TVT transobturator [in French]. Prog Urol 13: 115–117, 2003. 3. Meschia M, Pifarotti P, Bernasconi F, et al: Tension-free vaginal tape: analysis of outcomes and complications in 404 stress incontinent women. Int Urogynecol J Suppl 2: S24 –S27, 2003. 4. Tamussino KF, Hanzal E, Kolle D, et al: Tension-free vaginal tape operation: results of the Austrian registry. Obstet Gynecol 98: 732–736, 2001. 5. Soulie M, Cuvillier X, Benaissa A, et al: The tension-free transvaginal tape procedure in the treatment of female urinary stress incontinence: a French prospective multicentre study. Eur Urol 39: 709 –715, 2001. 6. Olsson I, and Kroon UB: A three-year postoperative evaluation of tension-free vaginal tape. Gynecol Obstet Invest 48: 267–269, 1999. 7. Azam U, Frazer MI, Kozman EL, et al: The tension-free vaginal tape procedure in women with previous failed stress incontinence surgery. J Urol 166: 554 –556, 2001. 8. Dargent D, Bretones S, George P, et al: Insertion of a sub-urethral sling through the obturator membrane for treatment of female urinary incontinence [in French]. Gynecol Obstet Fertil 30: 576 –582, 2002.
UROLOGY 64 (2), 2004