Management of Urethral Lesions and Urethrovaginal Fistula Formation Following Placement of a Tension-Free Suburethral Sling: Evaluation From a University Continence and Pelvic Floor Centre

Abstract

Introduction The complication of tape erosion in the urethra following placement of a retropubic (TVT) or transobturator (TOT) tension-free suburethral vaginal sling or an accidental iatrogenic transurethral tape position can result in the formation of a urethrovaginal or vesicovaginal fistula. The objective of the investigation is the evaluation of the management of such rare complications.

Patients and Methods Retrospective analysis of 14 patients who were treated for a urethral lesion or urethrovaginal fistula formation status post TVT/TOT placement between June 2011 and February 2018 in the Tübingen University Department of Gynaecology.

Results As surgical therapy, 57.1% (n = 8) cases underwent vaginal fistula closure using a Martius flap of the labium majus and in 21.4% (n = 3) using a vaginal rotation skin flap. In 21.4% (n = 3), exclusively vaginal suture reconstruction of the urethra following excision of the tape running transurethrally or tape erosion was performed. 50% (n = 7) of the patients had lasting continence postoperatively without any further need for therapy. In 28.6% (n = 4), there was ongoing stress urinary incontinence, in 21.4% (n = 3) mixed urinary incontinence. Six of the 7 patients with persistent incontinence underwent new placement of a tension-free suburethral retropubic sling (TVT) an average of 8.8 months (5 – 13 months) postoperatively which was uncomplicated in all patients and achieved satisfactory continence. The 3 patients with mixed urinary incontinence and persistent urgency components additionally received anticholinergic medication. During the time period investigated, there were no long-term complications, in particular no recurrent fistulas.

Conclusion The rare but relevant complications of a urethral erosion, transurethral tape position or urethrovaginal fistula formation status post TVT/TOT placement can be successfully managed via vaginal surgery. Persistent postoperative urinary incontinence with the need for a two-phase repeat TVT placement following sufficient wound healing must be preoperatively clarified.

Key words

urethrovaginal fistula - TVT erosion - urethral lesion - Martius flap

• References/Literatur

• 1 Reisenauer C, Muche-Borowski C, Anthuber C. et al. Interdisciplinary S2e Guideline for the Diagnosis and Treatment of Stress Urinary Incontinence in Women: Short version – AWMF Registry No. 015-005, July 2013. Geburtsh Frauenheilk 2013; 73: 899-903
• 2 Morton HC, Hilton P. Urethral injury associated with minimally invasive mid-urethral sling procedures for the treatment of stress urinary incontinence: a case series and systematic literature search. BJOG 2009; 116: 1120-1126
• 3 Goujon E, Jarniat A, Bardet F. et al. Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder. J Gynecol Obstet Hum Reprod 2018; 47: 289-297
• 4 Costantini E, Lazzeri M, Porena M. Managing complications after midurethral sling for stress urinary incontinence. EAU-EBU Update Ser 2007; 5: 232-240
• 5 Bader G, Koskas M. Complications of midurethral sling procedures for surgical treatment of female stress urinary incontinence. J Gynecol Obstet Biol Reprod 2009; 38 (Suppl.) S201-S211
• 6 Reisenauer C, Wallwiener D, Stenzl A. et al. Urethrovaginal fistula-a rare complication after the placement of a suburethral sling (IVS). Int Urogynecol J 2007; 18: 343-346
• 7 Wallwiener D, Jonat W, Kreienberg R, Friese K, Diedrich K, Beckmann MW. Hrsg. Atlas der gynäkologischen Operationen. 7. Aufl.. Stuttgart: Thieme; 2009
• 8 Amundsen CL, Flynn BJ, Webster GD. Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome. J Urol 2003; 170: 134-137 discussion 137
• 9 Zilberlicht A, Lavy Y, Auslender R. et al. Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap. Int Urogynecol J 2016; 27: 1925-1927
• 10 Reisenauer C, Janowitz J, Wallwiener D. et al. Urethrovaginal fistulae associated with tension-free vaginal tape procedures: a clinical challenge. Int Urogynecol J 2014; 25: 319-322
• 11 Reisenauer C. Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center. Arch Gynecol Obstet 2015; 292: 245-253
• 12 Sokol ER, Urban R. Novel repair of tension-free midurethral sling erosion into the urethra. J Minim Invasive Gynecol 2008; 15: 755-757
• 13 Blaivas JG, Mekel G. Management of urinary fistulas due to midurethral sling surgery. J Urol 2014; 192: 1137-1142