Objective
We sought to compare the development of paraurethral banding and subsequent dyspareunia in women undergoing either a transobturator (TO) or retropubic (RP) sling.
Study Design
We conducted a retrospective cohort study comparing women treated with either a TO or RP sling during a 10-month period.
Results
A total of 25 TO sling patients and 28 RP sling patients were compared in the study. Paraurethral banding was observed in 13/25 (52%) of the TO group compared with none in the RP group ( P < .001). Although no difference was noted in overall female sexual function index scores, de novo internal dyspareunia was reported in 4/17 (24%) of the TO group and none in the RP group ( P = .04). Paraurethral banding was observed in all patients reporting dyspareunia.
Conclusion
We have identified paraurethral banding as a previously unreported complication of the TO sling. Surgeons should be aware of paraurethral banding and subsequent internal dyspareunia as a potential complication.
Stress urinary incontinence (SUI) affects approximately 10–20% of women in the general population. There have been well over 100 different surgical procedures described to correct this condition in the past century. In the early 1990s Ulmsten et al introduced the “hammock hypothesis” and subsequently developed the tension-free vaginal tape (TVT) for treating female SUI. As described in this procedure, polypropylene mesh was used to provide the midurethral support with no tension. Initial reported cure rates were 85%. This procedure ushered in a minimally invasive surgical approach for treating patients with SUI. The retropubic (RP) sling has been widely accepted as the gold standard for the treatment of SUI.
Perioperative sling-related complications include bladder perforation, excessive blood loss, urinary retention, pelvic hematoma, and suprapubic wound infection. Later complications include exacerbation of existing or development of de novo overactive bladder, persistent suprapubic discomfort, and vaginal mesh erosion. Rare complications, such as bowel injuries and female sexual dysfunction, have been reported. The transobturator (TO) approach was developed by Delorme to reduce the complications typically associated with the traditional RP sling, including bladder perforation and bowel injury. His initial report showed 90% of the patients cured, with no perioperative complications and no postoperative voiding difficulties. With the exception of the TVT obturator (TVT-O), the TO technique involves inserting the polypropylene mesh through the obturator foramen, using the outside-to-inside approach. Even though there has been a decrease in the above-mentioned injuries, the typical sling-associated complications persist, including vaginal erosion. Furthermore, the US Food and Drug Administration-maintained Manufacturer and User Facility Device Experience Database has provided a series of reported complications associated with TO sling approach, including vaginal erosion, neuropathy, hematoma, urethral injury, and bladder perforation.
Our experience has allowed us to observe a previously unreported complication associated with the TO sling, namely, anterior vaginal wall banding in the paraurethral folds immediately adjacent to the midurethral placement of the sling. We became concerned that this phenomenon might lead to future problems, including internal dyspareunia. Therefore, we undertook this retrospective review of our series of patients who had undergone the TO sling to determine how many developed this paraurethral banding and whether they experienced sexual dysfunction as a result. We compared these with a cohort of a similar number of RP sling patients from the same time period.
Materials and Methods
During a 10-month period in 2005, 28 women with urodynamically confirmed SUI were treated with the TO sling and 42 received an RP sling. Table 1 describes patient demographic characteristics. This study was approved by the clinical investigation committee at Rochester General Hospital. All patients were evaluated before surgery, with a comprehensive review of their history, completion of a quality-of-life questionnaire, voiding diary, site-specific physical examination (Pelvic Organ Prolapse Quantification System), office cystourethroscopy, and multichannel urodynamic studies with microtip transducer catheters. Patients who opted for surgical management of their SUI were offered the TO sling if their upright maximal closure pressure exceeded 20 cm H 2 O with a symptomatically full bladder (>300 mL). Choice of sling was ultimately at the discretion of the operating surgeon. The TO sling was not used in patients with an upright maximal closure pressure of ≤20 cm H 2 O. The TO sling procedure was performed in a manner similar to the technique described by Delorme. Local, spinal, and general anesthesia was used according to patient and anesthesiologist’s preference. The polypropylene mesh sling (Obtryx; Boston Scientific Inc., Natick, MA) was inserted through the obturator foramen, using the outside-to-inside approach. The graft was positioned at the midurethra with no tension. Intraoperative cystoscopy was performed to evaluate the integrity of the bladder prior to completion of the TO sling. The RP sling (Advantage; Boston Scientific Inc.) followed the technique described by Ulmsten et al. All procedures were performed by surgeons experienced in both TO and RP sling procedures using a standardized technique under the supervision of the senior author. Intravenous prophylactic antibiotics were used in all patients.
| Characteristic | TO (n = 25) | RP (n = 28) | P value |
|---|---|---|---|
| Age, y a | 56.6 ± 14.1 | 63.1 ± 11.3 | .068 |
| Parity a | 2.7 ± 2.1 | 2.8 ± 1.3 | .771 |
| BMI a (kg/m 2 ) | 28.8 ± 4.0 | 29.3 ± 4.8 | .674 |
| Sexually active b (preoperatively) | 17 (68.0) | 16 (57.1) | .571 |
| Concurrent surgery for prolapse b | 14 (52.0) | 14 (50.0) | .785 |
a Data presented as mean ± SD, t test;
Postoperative follow-up involved a comprehensive site-specific pelvic examination (Pelvic Organ Prolapse Quantification System). In addition, a careful visual inspection and digital palpation of the anterior vaginal wall was conducted to assess vaginal epithelial healing and to uncover palpable banding of the mesh beneath the healed epithelium in the area of the paraurethral folds. The examiner was blinded as to which surgery was performed; however, the examiner was aware of any complaints of dyspareunia and used the information in attempting to ascertain the source of the discomfort during the physical examination. Furthermore, patients were asked if they felt any discomfort with direct palpation of the paraurethral areas whether or not bands were detected. A validated female sexual function index (FSFI) was also used to assess pain with sexual intercourse and/or differences in sexual function related to each sling type.
Results
During the 10-month study period 28 patients received the TO sling and 42 the RP sling. A total of 25 TO sling patients (89%) and 28 RP sling patients (67%) were evaluated postoperatively, with a mean follow-up of 38 months. Using supine and standing stress tests, we observed a 92% objective cure rate in the TO group and a 96% cure rate in the RP group, with the remaining 7% and 4%, respectively, reporting significant improvement. The TO group had 1 complication involving a through-and-through vaginal wall perforation that was recognized intraoperatively and corrected. Other complications, such as bladder perforation, vaginal erosion, obturator hematoma, and voiding dysfunction, were not observed. In the RP group 3 bladder perforations were observed and corrected intraoperatively.
Prior to the sling procedure, 17/25 (68%) in the TO group and 16/28 (57%) in the RP group reported being sexually active. None had intercourse-related discomfort. Postoperatively, 13/25 (52%) of the TO patients displayed the paraurethral banding phenomenon compared with none of the RP patients ( P < .001). Only 4 of the 12 (25%) patients with banding had undergone the TO sling procedure alone. The remaining 8 cases of banding (75%) were found in patients with TO slings and other concomitant procedures. Overall, 4/17 (24%) women who reported no problems with sexual activity before surgery complained of de novo internal dyspareunia after the TO sling procedure compared with none of the women undergoing the RP sling ( P = .04). All 4 of the TO women displayed banding. The remaining 8 women with paraurethral banding did not report dyspareunia ( Table 2 ).
