V1-14: Repair of complete urethral disruption due to synthetic sling complication
VideoIntroductions and Objectives
Urethral complications due to synthetic mid-urethral slings are rare. Possible causes may include unrecognized trocar injury, mesh implantation despite recognized injury, mesh contamination leading to inflammation and delayed perforation, and excessive sling tension. There is no consensus as to the surgical management of urethral complications with regard to how much mesh should be excised, whether an interposition flap should be utilized, and whether a pubovaginal sling should be placed at the time of surgery. We present a case of complete urethral disruption due to a synthetic mid-urethral sling complication.
A 56 year old woman was referred for a hole in her urethra. She reported mixed urinary incontinence requiring 6 pads per day. She denied continuous incontinence, split stream, or recurrent UTI. Her surgical history was significant for prolapse repair and synthetic transobturator sling surgery complicated by synthetic sling extrusion with subsequent sling revision. Physical exam revealed complete urethral distraction distal to the bladder neck. The proximal urethral segment was about 2 cm in length and the distal urethral segment about 1 cm in length. The patient also had stage 3 pelvic organ prolapse. Cystoscopy confirmed that the urethral distraction was distal to the urethral sphincter. The bladder was normal.
The patient was counseled regarding surgical repair of the complete urethral distraction. A primary end-to-end urethral reconstruction was performed. Any residual synthetic mesh was excised. Given the good tissue quality and water-tight closure, we did not place an interposition flap. We also opted not to address her stress incontinence with concomitant fascial sling placement as we did not want to compromise the urethral repair. VCUG was performed after 3 weeks revealing no extravasation. The foley catheter was removed. On follow-up the patient reports bothersome urgency incontinence. She denies stress urinary incontinence.
Complete urethral disruption is a rare complication of synthetic mid-urethral sling surgery, that can be repaired primarily with good results. There is no consensus regarding the surgical management of such complications and thus an individualized approach should be used based on the patient’s presentation and surgeon expertise.