A 44-year-old woman presents with a history of recurrent urinary tract infections (UTIs) and stress urinary incontinence (SUI). She reports symptomatic culture-proven UTI about four or five times per year. The UTIs are not associated with anything that the patient can identify and typically respond to antibiotics within 2 to 3 days. In addition, for the past 2 years, she has had significant SUI that occurs when she bends, walks, and moves quickly, as well as with coughing and sneezing, and more strenuous activities. Overall, leakage has progressed in the past 6 months. She also has urgency incontinence one or two times per day, but says that this is not as significant as the SUI. She denies any difficulty emptying her bladder. She has developed new-onset painful intercourse. The history is also significant for a retropubic midurethral sling that was placed for SUI 7 years prior to presentation. The surgical procedure successfully treated her SUI for 5 years, until it recurred 2 years ago. On physical examination, her abdomen is soft and nontender. Pelvic examination reveals healthy vaginal epithelium, with no evidence of exposed mesh, no significant pelvic organ prolapse, and suburethral tenderness that mimics the discomfort that she has with intercourse. She has urethral hypermobility, but stress incontinence is not demonstrated. Her post void residual is zero.
Cystourethroscopy revealed an eroded, calcified mesh sling throughout the urethra. The rest of the examination yielded unremarkable results. Urodynamic evaluation showed urodynamic stress incontinence, with a low abdominal leak point pressure (64 cm H2O), no detrusor overactivity, and no evidence of obstruction.
This case demonstrates three learning points. The first has to do with the eroded synthetic sling. Any patient who has had a synthetic sling who presents with recurrent UTIs, pain, or hematuria should undergo a cystoscopy as part of the workup. The incidence of urethral erosion after midurethral sling placement is low, approximately 0.064% in one large study,1 and UTIs are known to occur after sling placement in the absence of erosion.2,3 However, if there is a urethral erosion, it must be addressed. In this case, the delay in diagnosis made the case more complicated because there was stone formation on the sling. Various treatments for urethral erosion have been described, including endoscopic incision with laser4,5 or scissors, as well as open removal. Rates of recurrent erosion with endoscopic excision have been reported to be as high as 66%.4 We believe that open removal is best because it ensures that all the mesh is removed and it limits recurrence.
The second learning point has to do with the evaluation of this patient’s incontinence. She complains of SUI, but it is not observed initially on physical examination. She also has daily urgency incontinence and has had prior SUI surgery. Most experts agree that this is not a case of uncomplicated SUI, in which urodynamic testing is not necessary.6 Therefore, if one is considering treating SUI, this patient should be evaluated with urodynamics. In this case, the diagnosis of SUI was confirmed.
The final learning point has to do with treatment. It is indisputable that the erosion must be taken care of. The question is whether to treat the recurrent SUI at the same time. This is where evidence-based guidance is limited. In our experience, among patients who do not have SUI, 40% will require a subsequent surgery to treat SUI and 60% will not. This is like the rates reported in the literature.7 We do not expect SUI that is present prior to removal of an eroded sling to resolve with sling removal. The best simultaneous treatment or prevention of SUI at the time of midurethral sling removal and urethroplasty involves placement of an autologous fascial pubovaginal sling (rectus fascia or fascia). Because this will increase morbidity and recovery time, it is our recommendation to not place a pubovaginal sling if there is no SUI present and to place one if SUI is present. However, we must be clear that there are no studies comparing single versus staged sling placement for either treatment or prevention of SUI. Therefore, at this time, the decision remains a patient-surgeon choice.
The patient underwent removal of the eroded midurethral sling, urethroplasty, and placement of a rectus fascia pubovaginal sling. The eroded sling was isolated on either side of the urethra and cut laterally on both sides. The suburethral segment was then mobilized toward the urethra on both sides. The periurethral fascia was opened and a controlled urethrotomy was made. The sling and attached stone were removed in their entirety. The urethral incision was closed, followed by closure of the periurethral fascia, and then the fascial sling was placed. A Foley catheter was left indwelling for 3 weeks, and a voiding cystourethrogram showed healing of the urethra. At 5 months after surgery, she is free of SUI and has some urgency, with an occasional bout of urgency incontinence that she can manage without medication.
