À propos d’une exposition vésicale bilatérale très tardive d’un TVT rétropubien

25 septembre 2020

Auteurs : L. Pencole, P. Dewaele, Y. Athiel, S. Abgrall, A. Fechner, V. Cardot, X. Deffieux
Référence : Prog Urol, 2020, 11, 30, 618-619




 



A 67-year-old woman presented with recurrent urinary tract infections, nocturia and chronic pelvic pain lasting for one year. We noted in her medical history a retropubic tension-free vaginal tape (TVT) procedure 20 years ago for stress urinary incontinence. Physical examination did not reveal any vaginal sling exposure. Pelvic ultrasound and CT scan revealed a calcified structure 20×21mm at the anterolateral wall of the bladder (Figure 1). Urethrocystoscopy revealed bladder exposure of 3cm of TVT on the right side, with a calculus/lithiasis on the sling (Figure 2 and Appendix A). On the left side, we noted a small prosthetic exposure associated with a millimeter-sized calculus/lithiasis. No urethral sling exposure was observed. The removal of both sides of the sling was scheduled by a laparoscopic and cystoscopic approach. The retropubic TVT procedure has for more than 20 years been one of the first-line surgical therapies for female urinary stress incontinence and stress-dominated mixed urinary incontinence in women. After 17-year follow-up, 80 to 90% of patients declared themselves cured [1]. Bladder sling exposure of TVT is an uncommon complication (0.3%) and most erosions described in the literature appear within two years after the insertion [2, 3]. Short-term postoperative bladder sling exposure is probably a consequence of undiagnosed perioperative bladder injury. However, long-term bladder sling exposure is related to progressive migration of the sling. Multiple factors may be involved in progressive "erosion/extrusion" of the sling in the bladder: perioperative involuntary submucosal sling placement, inflammation phase of the foreign body reaction, matrix formed around the sling, chronic phase of the inflammation, systemic inflammation, etc. Further knowledge of the influence of polypropylene itself on wound healing and exposure/erosion mechanisms will be important. The majority of patients presenting with bladder sling exposure reported recurrent UTIs associated with irritative complaints including frequency, urgency and nocturia and/or pain [3]. Finally, surgeons and patients should be aware of the risk of very late bladder sling exposure after a TVT procedure.


Figure 1
Figure 1. 

Computed tomography (axial; contrast injected). Arrow: right sided calculus/lithiasis into the bladder.




Figure 2
Figure 2. 

TVT bladder exposure during urethrocystoscopy. a. TVT right bladder exposure. b. TVT left bladder exposure (arrow).





Disclosure of interest


The authors declare that they have no competing interest.



Appendix A. Supplementary data


(3.89 Mo)
  



References



Braga A., et al. Tension-free vaginal tape for treatment of pure urodynamic stress urinary incontinence: efficacy and adverse effects at 17-year follow-up BJU Int 2018 ;  122 (1) : 113-117 [cross-ref]
Holdø B., Verelst M., Svenningsen R., Milsom I., Skjeldestad F.E. The retropubic tension-free vaginal tape procedure - Efficacy, risk factors for recurrence and long-term safety Acta Obstet Gynecol Scand 2019 ;  98 (6) : 722-728 [cross-ref]
Forzini T., Viart L., Alezra E., Saint F. Erosive complications of mid urethral slings (MUS): 10 years of surgical experience Prog Urol 2015 ;  25 (5) : 240-248 [cross-ref]






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