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Understanding the occurrence and management of mesh kit complications has become increasingly important. A 54-year-old woman presented to our tertiary care center with complaints of constant perineal pain, and copious, foul-smelling vaginal discharge after anterior and posterior placement of a synthetic mesh and mid-urethral sling 3 months earlier. She was found to have two vaginocutaneous sinus tracts (to the left ischiorectal fossa and to the left labia majora), as well as bilateral abscess cavities within the ischiorectal fossae. The posterior mesh was completely excised, the tracts were opened, and the wound was packed and allowed to heal by secondary intention.

Introduction and Hypothesis: We compared cure rates of tension-free vaginal tape (TVT) with intravaginal slingplasty (IVS) and evaluated changes in cure rates over time., Methods: One hundred three underwent TVT and 213 underwent IVS. Follow-ups were done at 3 months, 1 year, and 5 years., Results: The following results were found: objective cure for TVT 98-95-94% vs. IVS 86-86-80% (p < 0.03); subjective cure for TVT 82-79-74% vs. IVS 79-81-71% (NS). In IVS, a significant decline in subjective cure took place. Vaginal erosions were found in 11.8% of women in the IVS group and none in the TVT group., Conclusions: TVT is an effective and stable treatment, whereas IVS has a significant inferior objective cure rate, and a significant decline in subjective cure rate occurred over time. A high rate of vaginal erosions was found in the IVS group. We cannot recommend the use of multifilament polypropylene tape (IVS) for surgical treatment of stress urinary incontinence.

Sparse information is available regarding erosion following biomesh implantation. We report two cases of erosion following anterior vaginal wall repair. In both cases, the operation was performed as a standard cystocele repair where the collagen Pelvicol mesh was anchored to the pubocervical fascia. Both patients had signs of erosion shortly after the operation, and both had the mesh removed. In one patient, the vaginal epithelium healed spontaneously, whereas the other patient had a delayed healing process. The graft was rejected due to intolerance to the biomesh or an infection. Our study shows that an erosion following implantation of a biomesh may be complicated.

A 50-year-old diabetic woman was referred to our unit because of high fever, foul-smelling vaginal discharge and pain in the leg, 7 months after undergoing surgery for application of a transobturator suburethral sling. Patient evaluation revealed erosion of the tape through the vaginal wall; the infection had spread to the region of the internal obturator muscle and then up to the anterior recess of the ischiorectal fossa. The patient underwent surgery for sling removal, antibiotic therapy and, finally, surgical incisions to facilitate drainage of the abscess. All these passages were necessary to obtain complete resolution of the symptoms. Infectious complications are possible after transobturator sling procedures. Patients should then be informed about the risks of erosion and infection and be warned that the appearance of pain and foul-smelling vaginal discharge may indeed be the first symptom of subsequent and much more severe infectious complications.

We present a case of prepubic and thigh abscess after the placement of two types of suburethral slings in a 65-year-old woman suffering from stress urinary incontinence (SUI). The first surgical procedure (prepubic tension-free vaginal tape) was unsuccessful. Thus, 2 months later, we placed an ObTape sling by transobturator approach. This second procedure was successful. Seven months later, the patient presented with vaginal erosion of the sling with no inflammatory signs. The suburethral portion of the sling was immediately removed and the vagina was sutured. Nine months later, a prepubic abscess occurred and required removal of the prepubic sling, drain placement, and antibiotic therapy. Unfortunately, 9 months later, a thigh abscess occurred. Magnetic resonance imaging (MRI) allowed precise diagnosis and anatomic localization of the thigh abscess. Surgery consisted of opening and draining the abscess and removing the transobturator sling. At 6 months follow-up, no persistent inflammatory sign was observed on MRI, and SUI did not recur.

Since the beginning of use of synthetic midurethral slings, several complications, usually benign, have been reported. Recently, three consecutive cases of severe thigh infection secondary to transobturator insertion of a synthetic tape alarmed us. This is a case report about these three cases and a review of literature about complications of transobturator tapes.

Transobturator sub-urethral tapes are emerging as one of the surgical options for the management of urodynamic stress incontinence. Though with relatively less risk of injury to the bladder, a different approach as well as the different characteristics of the tape material mean a variety of complications like obturator abscess, obturator haematoma, retro-pubic haematoma, and perineal cellulitis. In this paper, we describe a case of perineal cellulitis following the insertion of a transobturator tape (Obtape). Though cellulitis was managed conservatively with intravenous antibiotics, the patient was found to have vaginal extrusion of the tape. Vaginal erosion was initially managed with resuturing of the vaginal wall. Persistent erosion unfortunately necessitated complete tape removal. The patient later had another sub-urethral procedure after 3 months. Perineal cellulitis is rare after transobturator tape procedures. In the literature, only two cases have been described so far. Though vaginal erosion can be managed conservatively, we recommend the complete removal of the tape when an infection is proven or suspected.

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30-83 years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1 months (range 7.5-59.9) in the Gynemesh group and 7.1 months (range 1-21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70 years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3-9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1-0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70 years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.

Transobturator Prolene tape insertion represents a new method of operative treatment for stress urinary incontinence. The first results show that it is a simple and effective procedure accompanied by a minimum number of complications. Since February 2004, 30 Monarc procedures were done at our department and no intraoperative complications were observed. However, two cases (6.7%) of vaginal wall erosion due to the Prolene tape were noted 6 weeks after surgery. In a subsequent surgical procedure, the periurethral portion of the tape was removed and a new Prolene tape was placed through the retropubic space. Three months after secondary surgery both patients were continent, with no sign of erosion. The transobturator approach was introduced to minimize the risk of complications. However, the greater prevalence of vaginal wall erosion after this procedure found in our series demands a scrupulous search for this complication and for the mechanisms leading to its occurrence.

The intravaginal midurethral sling operations have become a trend to treat female stress urinary incontinence. Cases of complications requiring surgical revision are rarely reported. We report on seven patients with complications necessitating surgery. Six patients with vaginal erosion were treated with transvaginal excision of migrated tape and fibrotic tissues around the vaginal wall, and one patient with bladder erosion was treated with suprapubic minimal laparotomy and transvaginal partial excision of the tension-free vaginal tape (TVT). The incidence of polypropylene mesh erosion was 1.1% in this study. All patients recovered well from our surgical intervention, except the bladder erosion patient who needed anticholinergic medication to treat postoperative urgency and urge incontinence.

We report an unusual case of suburethral vaginal erosion and pyogenic granuloma formation 14 months after intravaginal slingplasty (IVS). A 64-year-old woman underwent IVS for recurrent stress incontinence 12 years after Burch colposuspension. Following seemingly uncomplicated surgery and recovery, she developed a recurrent urinary tract infection which was treated with antibiotics. When she presented with vaginal pain and postmenopausal bleeding approximately 14 months postoperatively, she was found to have suburethral vaginal erosion of the tape and a pyogenic granuloma. The exposed tape was removed, the granuloma excised, and the overlying vaginal skin was then closed. She then made an uneventful recovery.

When evisceration occurs through a large enterocele surgical repair can be performed vaginally, including bowel resection and reanastomosis, thereby avoiding the morbidity associated with laparotomy.

Symptoms of bladder irritability are common after incontinence surgery but their cause is unknown. This study tests the hypothesis that irritative symptoms after colposuspension are due to distortion of the trigone. As part of longitudinal follow-up studies, 175 women were examined 6 months to 12 years after either an open or a laparoscopic Burch colposuspension. The main outcome measures were symptoms of bladder irritability (frequency, nocturia and urge incontinence) and ultrasound findings (bladder neck position at rest and on Valsalva, the presence of a colposuspension ridge, ridge depth and ridge distance, and trigonal angle). Two positive associations between ultrasound parameters and symptoms of bladder irritability were observed: urge incontinence was more likely in the presence of bladder neck funneling, and women with nocturia had a higher trigonal angle. Increased distortion of the trigone was associated with a reduced incidence of urge incontinence in the subgroup of patients after laparoscopic colposuspension. The data presented in this study do not support the hypothesis that symptoms of bladder irritability are due to trigonal distortion or overelevation.