Management of Urinary Fistulas Due to Midurethral Sling Surgery

Abstract

With careful attention to surgical principles and technique, including removal of as much of the adjacent mesh as possible, a successful outcome can be achieved in most patients with a fistula secondary to mid urethral sling surgery.

Evaluation and Management of Mid-Urethral Sling Complications

“…Of these 7/10 underwent a successful fistula repair. One of the patients had a urinary diversion while the other 9/10 underwent primary repair with an interposition graft (Martius flap, omental flap, bladder wall flap, or autologous sling) [63]. While the majority of patients in this series had a successful repair, results can be quite variable.…”

Safety considerations for synthetic sling surgery

“…The effects of long-term pain receive no attention at all in any study except for a few case studies of complications. 9,[40][41][42][43][44] The concomitant, widespread use of two different generic sling designs (RP and TOT) with different implantation techniques and at least 41 different commercially available kits, 42 each having different sling and trocar characteristics with potentially different complication profiles, confounds accurate analysis of sling complications. These different characteristics might also portend different complication profiles, yet studies of sling complications almost never distinguish between the different kit types and many do not even separate TOT from RP slings.…”

“…6 Furthermore, this study 6 excluded patients whose slings were removed owing to pain and other indications, thus the actual incidence of sling removal owing to complications is probably even higher than that. Extrapolating from this estimate and the estimated number of slings implanted in the 6,9,10,41,44,[100][101][102][103][104][105][106][107][108][109][110][111][112][113][114] Use of imperfect research methodologies, a lack of long-term follow up and reporting bias have been suggested as causes of these differences. 10,45,115,116 Safety and risk:benefit considerations Safety of SMUS surgery refers to the probability of any adverse event, while risk describes the range and probability of specific adverse events.…”

“…In addition, secondary voiding problems can arise after sling revision or excision surgeries performed to treat the original complications such as recurrent SUI, dyspareunia, urethral strictures and fistulas. 41,100,111,244 We used our best judgement to assign the authors' intent to one of the categories listed below, but in some instances the author's intent was not clear. For example, one category was listed as "voiding dysfunction requiring surgery", 30 although whether this was a result of urethral obstruction or refractory OAB was not defined.…”

“…324 Larger mesh exposures require primary closure of the vaginal wall over the exposed mesh or surgical excision and closure with or without vaginal wall flaps. 30,[41][42][43]45 Mesh exposures of this type are usually reported as minor complications; post-treatment follow up in these patients has been woefully inadequate in most studies. 319,[323][324][325] We did not find sufficient justification in the literature to be able to confidently assess the long-term success of treating these minor exposures.…”