1. Complications associated with SUI and POP surgery
Ju Tae Seo, MD
Department of Urology
Cheil General Hospital
Kwandong University College of Medicine

2. Introduction
Women have an 11% lifetime risk of one operation for POP or SUI
Midurethral sling for SUI
1) retropubic MUS ; TVT, SPARC, IVS, TVA, Iris, Serapren tape, Advantage, T-sling, Continence, Safyre, Seratom
2) transobturator MUS ; TVT-O, TOA, MONARC, TOT, CM-sling, Osiris, Lynx
3) New slings ; TVT-Secur, MiniArc
Mesh for POP surgery
; Prolift, Apogee, Perigee

3. The incidence of major complications may be underreported.
A significant discrepancy between scientific reports and FDA/MAUDE reports
1) reports may understate complications
2) surgeons with higher complication rates do not answer questionnaires
3) differences exist between high- and low-volume surgeon
4) Complication rates accounted for by surgeons who manage the complication

4. Co-morbidities increase the incidence of complications
Diabetes and vascular lesion
; a 2-fold increase in the risk of major Cxs (sepsis, pulmonary failure, MI and thrombo-embolic events)
Obesity (BMI≥35kg/㎡)
; increase technical difficulty and Cx rates (deep vein thrombosis, arrhythmia, pneumonia)
Previous radiation for pelvic cancers

5. Complications after midurethral sling procedure and POP surgery
Intra-operative complications
: clinically significant bleeding & hematoma
: bladder, urethral, vaginal wall perforation
: bowel, nerve injury
Postoperative complications
: UTI
: Mesh erosion (vaginal & urethral)
: De novo urgency
: postoperative voiding dysfunction

6. Operative complications of MUS procedure

7. Bleeding and hematoma
Highly vascular venous space of Retzius(pelvic floor vein, epigastric vessel) or obturator or iliac vessels
Mean distance from TVT trocar to the major vessels is 3.2 to 4.9 cm and vascular injuries involving large arteries(ext. iliac, femoral, obturator, epigastric, inf. Vesical) are rare
Minor bleeding in retropubic procedure may related to the close positioning of dorsal vein of clitoris under the inferomedial aspect of pubic bone
Risk is high in patients with previous surgery in Retzius space
In TVT
; significant blood loss from 1.1 to 2.3%
; retropubic hematoma from 2.0 to 4.1%
In TOT
; 1-2% of the cases
- heavy intraoperative bleeding, pelvic, retropubic hematoma, and perineal, labial, or thigh hematoma

8. Management depend on extent of bleeding
: transfusion
embolization
hematoma drainage
laparotomy
Most retropubic venous bleeding
- managed with observation only
- two finger or gauze compression for 5 minutes just after surgery

9. Bladder perforation
More common in retropubic sling (0.7~24%), lower in transobturator sling(0~1%)
Risk factors ; previous anti-incontinence surgery, pelvic surgery, surgeon’s experience
Austrian TOT tape registry comprising of 2,541 cases
- 10 bladder and 2 urethral perforation
A retrospective study by Barber et al of 390 patients treated with TOT
- 2 bladder and 2 urethral injuries were reported
Careful and circumferential cystoscopic examination of distended bladder
 trocar is removed and repassed
 cystoscopy is repeated with each pass of the trocar

10. Bladder and urethral injury
Tips in difficult situation
- injection of normal saline behind the pubic bone in the intended path of needle
- passing the needle from the suprapubic incision to the vaginal tunnel
Recommendation of universal intra-operative cystoscopy in cases of previous extensive pelvic surgery and difficulty of needle passage
No need any further therapy except catheter drainage for 2-4 days
Undiagnosed bladder & urethral injuries
- hematuria, pain(suprapubic/urethra), recurrent UTI, stone, voiding dysfunction, fistula
The mesh must be removed completely.
The earlier a misplaced tape is explanted, the fewer the scar, the less inflammation will develop, and the easier complete removal will be.

11. Urethral perforation by TOT procedure

12. Vaginal wall perforation
majority occurred in the transobturator slings (2.3~12.9%)
Especially in pts without lateral defect of cystocele ( high position of lateral sulcus), risk of vaginal wall perforation is increased.
Careful vaginal wall inspection just after trocar or introducer passage (inside-out & outside-in)
Management – repositioning of trocar and simple suture of vaginal wall

13. Bowel injury A rare complication documented in case report
A greater risk in patients with Hx of previous abdominal or pelvic surgery
- adhesion in the Retzius space
No data on bowel injury with transobturator approach
Rectal perforation is not rare in post. transvaginal mesh repair (4~5%)
: simple suture and NPO for 5~7 days

14. Rare cases of major complications
Bowel, vascular, and nerve injuries
Necrotizing fasciitis
Ischiorectal, obturator abscess
Sepsis
Patient deaths
Extremely uncommon (86/11,800 cases)
- 32 vascular, 33 bowel injuries
- 8 patients death after TVT placement
Major complications might be underrepoted in the literature.

15. Operative complications of POP surgery

16. Complications Intraoperative During and after surgery Hemorrhage
< 2% with injuries (Ureteral, bladder, urethral, gastrointestinal )
During and after surgery
Infections (cuff cellulitis, abscess)
Bleeding
Urinary retention, bowel obstruction
Rectal injury, bladder injury
Mesh erosion, infection, vaginal granulation
Fistulas (ureterovaginal, vesicovaginal)
Ileus
Recurrence
Leg pain (esp, transobturator approach)
Persistent dyspareunia, pelvic pain, vaginal stenosis
Voiding dysfunctions

17. New Pelvic Symptoms after Reconstructive Pelvic Surgery
Thythy Pham et al. Am J Obstet Gynecol 2009;200:88.e1-e5.

19. A Long-Term Treatment Outcome of Abdominal Sacrocolpopexy
57 women who underwent ASC with mesh for symptomatic uterine or vault prolapse
The median follow-up was 66 months (range )
Jeon MJ et al. Yonsei Med J 2009;50:

20. Meshes and trocars for POP surgeries

23. Ant. and Post. mesh(Prolift) for POP surgery

24. Prolift System for Repair of Pelvic Organ Prolapse
Early outcome results from a retrospective study of 687 pts in 7 centers of France
: Intra-operative and short-term post-operative complication rates ranged from 0.15% to 1.75%
: Mesh erosion rates ranged from 0% to 13.3%
: Cure rate at 10 months – 95%
US based study including 350 pts
: Cure rate at 14 months – 91%
: Mesh erosion rates were <2%, conservative treatment or “in office” surgical correction
: Intra-operative complications ranged from 0.3% to 2.6% (cystotomy - most common Cx)
: Post-operative de novo OAB, voiding dysfunction, and SUI were seen in 4%, 2% and 3% of pts, respectively

26. Mechanism or Hypothesis
Postoperative voiding dysfunction may be caused by
Detrusor instability
Urethral obstruction
Recurrence of the cyctocele
Factors related to the development of urinary retention following SUI surgery
- Pre-operative Qmax
- Decreased detrusor pressure
- Straining during voiding
- Bladder neck elevation during surgery

27. Mechanism or Hypothesis
Increased amount of blood loss is associated with postoperative urinary retention
- First, more blood loss may result in hematoma formation acting as a non- functional, obstructive sub-urethral mass
- Second, more blood loss may be related to more extensive damage to the innervation of the detrusor muscle when surgery gets more complicated
Disturbed pelvic floor relaxation due to post-operative pain, intrinsic damage to the innervation of the bladder and BOO can contribute to the development of urinary retention following vaginal prolapse surgery
These hypotheses will be tested in future prospective studies.
Robert A et al. Neurourology and Urodynamics 2009;28:225–8.

28. Postoperative voiding dysfunction
Resolution of preoperative urgency in ≥63% of patients
De novo detrusor instability in 5%
Prolonged urinary retention in <1% of women
Nguyen et al. J Urol 2001;166:

29. Postoperative voiding dysfunction
New urge incontinence was the most commonly cited reason for patient dissatisfaction 1 year after surgery
Patients dissatisfied after retropubic midurethral slings were more likely to report urinary leakage, overactive bladder symptoms, and voiding dysfunction
Development of new pelvic symptoms after reconstructive pelvic surgery can adversely affect patient satisfaction, symptom improvement, and quality-of-life measures
Mahajan ST et al. Am J Obstet Gynecol 2006;194:722-8.
Davis TL et al. Am J Obstet Gynecol 2004;191:
Thythy Pham et al. Am J Obstet Gynecol 2009;200:88.e1-e5.

30. Stress urinary incontinence after transobturator mesh for cystocele repair
Cystocele repair can lead to de novo SUI or exacerbate pre-existing SUI
93 patients after a transobturator mesh procedure
57 women had not undergone a concomitant anti-incontinence procedure
Median follow-up: 9 months
87.5% (21/24) of patients with preoperatively SUI reported cure/improvement
one patient (4.2%) reported worsened SUI
21.2% (7/33) complained of de novo SUI
 Transobturator mesh for cystocele repair appears to have a net positive effect on SUI.
Shek KL et al. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:421-5.

31. Conclusions
High rates of new symptoms after MUS & reconstructive pelvic surgery were reported
These symptoms are associated with decreased self-reported improvement and satisfaction despite objective cure
Patients should be counseled carefully prior to surgery