Department of Urology, Lister Hospital Stevenage, Stevenage, UK.
BJU Int. 2010 Nov;106(10):1514-8. doi: 10.1111/j.1464-410X.2010.09378.x.
To present a series of women with late presentation of mid-urethral synthetic slings perforating the bladder and their management, this is rare but can lead to significant morbidity with medico-legal consequences.
We retrospectively reviewed the case notes of nine women with urinary symptoms referred to our unit for further investigation after synthetic mid-urethral sling placement.
The women presented between 8 weeks and 18 months after initial sling placement. Eight patients underwent a tension-free vaginal tape insertion via the retropubic route and one patient had an 'outside-in' obturator sling with the I-Stop device (CL Medical, Lyon, France). The frequencies of presenting symptoms were: dysuria in six; recurrent urinary tract infection in four; frequency and urgency in four and pelvic pain in two. Seven of the nine women developed bladder calculi on the exposed sling material, all of which were visible on plain X-ray. In six women, perforations were present at more than one site; in three urethral perforation had occurred together with an anterolateral bladder injury and in the remaining three there was bilateral bladder perforation. Initial management included cystoscopy and cystolithopaxy followed by transurethral resection (TUR) of the visible prolene mesh into the detrusor muscle. One woman required two TURs to clear all the mesh. Two women required further open surgery to remove all of the remaining mesh, both for ongoing pelvic pain that resolved after revision surgery. All the women had resolution of symptoms but all had recurrent stress urinary incontinence after tape division/excision. We used a novel technique to remove intraurethral mesh using a nasal speculum urethrally and excising the tape under direct vision, where resection proved impossible due to poor endoscopic views, with significant risk of sphincter injury.
The possibility of unrecognized tape perforation or erosion must be considered in women with persistent urinary symptoms, infection or pain after any form of mid-urethral sling procedure. Bladder stones almost invariably develop if the exposed mesh has been present for >3 months. Most patients can be managed with endoscopic resection to remove all intravesical tape. Cystoscopy should remain a mandatory procedure together with any form of mid-urethral sling placement but does not prevent unrecognized perforations in inexperienced hands.
介绍一组中尿道合成吊带后膀胱穿孔的迟发性表现的女性患者及其处理方法，这种情况很少见，但会导致明显的发病率和医疗法律后果。
我们回顾性分析了 9 例因初次放置合成中尿道吊带后出现尿路症状而转至我们单位进一步检查的女性患者的病历。
这些女性在初次吊带放置后 8 周至 18 个月出现症状。8 例患者经耻骨后途径行无张力阴道吊带（TVT）植入术，1 例患者行“由外向内”闭孔吊带术联合 I-Stop 装置（法国里昂 CL Medical 公司）。9 例患者中，主要表现为：排尿困难 6 例；复发性尿路感染 4 例；尿频、尿急 4 例；盆腔痛 2 例。9 例患者中有 7 例在暴露的吊带材料上形成膀胱结石，所有结石均在平片上可见。6 例患者的穿孔发生在多个部位；3 例患者出现尿道和前外侧膀胱损伤穿孔，另外 3 例患者出现双侧膀胱穿孔。初始治疗包括膀胱镜检查和膀胱结石碎石术，随后行经尿道切除（TUR）将可见的膨体聚四氟乙烯网片切除至逼尿肌内。1 例患者需进行 2 次 TUR 才能清除所有网片。2 例患者因持续的盆腔痛而需要进一步行开放性手术切除所有剩余的网片，术后疼痛缓解。所有患者症状均得到缓解，但所有患者在吊带切开/切除后均出现复发性压力性尿失禁。我们采用一种新的技术，使用鼻窥镜经尿道将尿道内网片取出，并在直视下切除吊带，对于因内镜视野不佳而无法切除的患者，采用这种技术可显著降低括约肌损伤的风险。
对于任何形式的中尿道吊带术后持续出现尿路症状、感染或疼痛的女性，必须考虑到未被识别的吊带穿孔或侵蚀的可能性。如果暴露的网片存在>3 个月，几乎都会形成膀胱结石。大多数患者可通过内镜切除来清除所有膀胱内的吊带。对于任何形式的中尿道吊带置入术，膀胱镜检查都应作为一种强制性程序，但在经验不足的医生手中，它并不能防止未被识别的穿孔。
