Introduction

Delayed mesh exposure of the tension free vaginal tape (TVT) procedure is rare. Studies have shown that the mean time for the onset of mesh exposure is 11.2 months postoperatively [1], and it rarely occurs after 1 year. A long-term study of 11.5 years of postsurgical outcome of TVT has shown an objective cure rate of 84 % but no incidence of mesh exposure [2]. However, the TVT has potential to erode the vagina and urinary tract, with rates of 0–2 % [3]. We report a case of vaginal and urethral mesh exposure that occurred 10 years after TVT placement.

Case

A 58-year-old multiparous and postmenopausal woman presented with predominant symptoms of stress urinary incontinence (SUI) and additional symptoms of urinary urgency and frequency in 2001. She has underlying diabetes mellitus, hypertension, and dyslipidemia, which are under control with medication. Physical examination revealed no pelvic organ prolapse (POP). Her body mass index (BMI) was 26.2 kg/m2. Initial investigation showed 1-h pad test of 89 g and postvoid residual urine volume of 30 ml. Urodynamic studies revealed mixed urinary incontinence (MUI).

The patient underwent TVT procedure after urinary symptoms of urgency and frequency were controlled with antimuscarinics and physiotherapy. After the surgery, she was followed up by the surgeon as scheduled. Her clinical symptom of SUI was cured, but overactive bladder symptoms recurred 6 months postsurgery. She was then started on continuous antimuscarinics and physiotherapy. Urodynamic studies 1 year postsurgery suggested detrusor overactivity. She presented with an episode of vaginal bleeding 2 years postsurgery. Physical examination revealed granulation tissue at the surgical site without vaginal tape exposure. The granulation tissue was excised under anesthesia, and a cystoscopy revealed a normal lower urinary tract. The patient was followed up for 5 years postsurgery and then 2-yearly, as requested by her.

In February 2011, the patient presented to the urogynecology clinic with complaints of urgency, urinary incontinence, and poor stream. Vaginal examination revealed an atrophic vagina without mesh exposure. One-hour pad test was 30 g; urodynamic studies showed MUI. Pelvic ultrasonography and cystoscopic examination were unremarkable. She was prescribed antimuscarinics and physiotherapy treatment again and followed up every 2 months. After 6 months, her clinical symptoms had improved; however, physical examination revealed a tiny vaginal mesh exposure without tenderness. She was counseled regarding management. She refused vaginal estrogen cream application but agreed to mesh excision under anesthesia. Intraoperative examination revealed vaginal tape exposure of 0.5 cm in length, and the distal edge of the tape was 0.5 cm from the urethral meatus (Fig. 1). Cystoscopy showed tape exposure in the posterior wall of urethra 0.5 cm from urethral meatus. However, the other parts of the urethra and bladder were normal. Category, Time, and Site (CTS) classification was 2AaT4S1 with 4BT4S1. A longitudinal incision was made on the anterior wall of vagina, and it was dissected to expose the tape. The tape was freed from the surrounding tissue and excised. The urethra and vagina were then closed in layers. Histology report from the excised vaginal tissue was acute and chronic inflammation, suggestive of actinomycosis. The patient was prescribed penicillin-based antibiotics, and recovery postoperatively was uneventful.

Fig. 1
figure 1

Vaginal tape exposure near urethral meatus

Full size image

Discussion

TVT is a monofilament Polypropylene type I synthetic mesh that carries a risk of mesh exposure of up to 2 % [3]. Mechanisms leading to exposure following synthetic suburethral sling implantation are still poorly understood. Various mechanisms have been suggested, which include subclinical infection of the sling leading to poor wound healing. Biomechanical properties of the graft materials may be associated with mesh exposure. Risk factors associated with exposure are diabetes mellitus (DM), (women with DM are 8.3 times more at risk than women without DM [4]), concomitant procedures (vaginal hysterectomy, genital prolapse surgery), previous incontinence surgery, and nonestrogenic state. Presumptive risk factors for urethral mesh exposure include urethral dilatation, sling misplacement, excessive tensioning, and local tissue infection [1]. Symptoms include vaginal discharge or bleeding, vaginal pain, suprapubic pain, recurrent urinary tract infection, hematuria, urinary incontinence, and perineal or urethral pain syndrome [1, 4]. However, some patients are asymptomatic, and therefore, vaginal examination plays an important role in detecting mesh exposure. Examination of the periurethral area of women with mesh exposure varied from granulation tissue, periurethral tenderness, or visible sling [1]. Cystoscopy helps diagnose urethral mesh exposure in women with persistent lower urinary tract symptoms.

Studies show that the mean time of mesh exposure is 11.2 months postoperatively; however, vaginal and urethral mesh exposure may be delayed for more than a year after surgery in up to half of patients [1]. Vaginal mesh exposure was not reported in a long-term study of 11.5 years [2], but Wadie reported a case of late complication of urethral mesh erosion 10 years after surgery, which was treated successfully by endoscopic excision [5]. In our case, the patient had vaginal and urethral mesh exposure with lower urinary tract symptoms. DM was a risk factor and was concomitant with subclinical vaginal infection, confirmed by histological diagnosis from vaginal tissue that revealed acute and chronic inflammation suggestive of actinomycosis. Penicillin-based antibiotic is required to treat this organism. Sonographic assessment of mesh position after surgery was not performed as a routine in our center 10 years ago. Hence, the correct position of the tape could not be determined. The distal position of the sling may have been due to incorrect positioning.

Treating vaginal and urethral mesh exposure includes conservative treatment with local estrogen cream application or surgical excision. This patient opted for surgical treatment and refused local estrogen treatment before and after surgery. Clemens et al. reported six patients with vaginal and urethral mesh exposure who underwent transvaginal sling removal and closure of the urethra. Postoperatively, the patients’ symptoms resolved; however, most patients experienced recurrent stress incontinence [1]. In our case, the urethral mesh erosion was recognized intraoperatively when performing cystoscopy. In view of the vaginal and urethral mesh exposure, mesh excision and repair was done transvaginally.

This case shows that, although rare, delayed mesh exposure can occur years after the TVT procedure. It would also be useful to form a registry of rare events so surgeons are aware of possible rare complications.