Infected Synthetic Mid-Urethral Sling: Mesh or Mess?

Introduction

Synthetic mid-urethral sling (MUS) relieves stress urinary incontinence, but can lead to bothersome mesh-related symptoms, which can be equally distressing. A case in which the patient had to undergo repeated abdominal and vaginal surgical interventions in view of persistent discharging suprapubic sinus and purulent vaginal discharge following synthetic MUS is reported.

Case

A 46-year-old woman was referred with chronic discharging suprapubic cutaneous sinus and vaginal discharge following synthetic MUS for treatment of stress urinary incontinence.

The patient underwent laparoscopic assisted vaginal hysterectomy in December 2005 for abnormal uterine bleeding. Retropubic synthetic mid urethral sling (tension-free vaginal tape [TVT]) was combined for significant stress urinary incontinence.

The patient developed bothersome discharge from the suprapubic exit site of the sling from the 3rd postoperative week onward, which was managed with antibiotics followed by exploration and closure of the wound, which provided only temporary relief. The abdominal discharge recurred after a month and was persistent. A year after the index surgery, she also developed distressing vaginal discharge caused by mesh exposure.

In view of her persistent complaints, a combined abdominovaginal surgical exploration was performed by the primary surgeon in November 2007 after excluding mesh exposure into the bladder or urethra on cystoscopy. Vaginal mesh exposure was managed by partial excision and closure of vaginal wall. Abdominal exploration included dissection and excision of the suprapubic sinus. Following temporary relief, the symptoms recurred within 3 months.

The patient approached the author 5 years following index surgery for persistent significant discharge, having been subjected to multiple surgical interventions (total three abdominal and two combined explorations) without relief.

A vaginal speculum examination revealed recurrent mesh exposure of 1×1 cm in the anterior vaginal wall 2 cm proximal to the external urethral meatus. Cystoscopy excluded exposure of mesh into the bladder or urethra. Abdominal ultrasound scan showed a sinus tract extending from the left end of the open wound up to the muscular plane.

Helical computed tomography (CT) with contrast revealed the following three ill-defined sinus tracts arising from anterior and lateral wall of vaginal vault and running posteroinferior to the urinary bladder (Fig. 1).

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FIG. 1.

Helical computed tomography (CT) showing the sinus tracts.

The sinus tracts were not communicating with the bowel loop, rectum, bladder, ureter, or urethra.

After a complete workup, a combined abdominovaginal approach was used to completely remove the infected mesh with the sinus tract (Fig. 2).

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FIG. 2.

Excised sinus tract and mesh.

An incision was made vaginally around the exposed mesh, and the mesh was dissected off the underlying tissue laterally on either side until the inferior pubic ramus, and was removed. An indwelling catheter was used as a guide during the surgery.

A suprapubic incision was made and the sinus tract was explored extraperitoneally. The retropubic infected sling on the left side, which was responsible for the cutaneous sinus, was dissected up to the Retzius space. It was relatively easier to remove the mesh on the left side, as it was partially integrated compared with the right side. A suprapubic drain was left, and the incision was closed.

Although the wound healing was delayed, the patient became symptom free at 2 months after the last intervention, and remained symptom free during the follow-up at 6 months. Despite complete removal of the mesh, she remains continent.

Discussion

Restoration of continence is the primary objective that is achievable with synthetic MUS, but the complications inherent to the synthetic sling causing newer symptoms may continue to compromise the patient's quality of life.

The overall incidence of mesh exposure as documented by a comprehensive review of suburethral sling procedure is 6.0%, and that for infections is 5.5%. ¹ However, the incidence of wound sinus formation with the use of synthetic mesh is as low as 0.007%. ²

Excision of the sinus tract alone, or partial removal of the infected exposed mesh, as was done for this patient, may require multiple interventions without offering cure. In such cases, the objective of exploration should be complete removal of the infected mesh rather than the infected tissue. Although fibrosis and tissue ingrowth can make the complete removal of mesh difficult, nonintegration of the mesh caused by infection, on the other hand, makes it possible.

This case emphasizes the inability to cure the patient of her symptoms, despite multiple surgical interventions, with the infected mesh in situ, and forewarns that a simple sling may turn complicated.

Conclusions

Relief from chronic suprapubic sinus and vaginal mesh exposure caused by an infected synthetic MUS can be achieved only with complete removal of the sling.