JRM 47: 4/2000 #4, 325-326

Abstract

Background: As new variations of operations are performed complications must be recognized and reported. Erosion of staples into the bladder following a mesh and staple colposuspension is a complication that must be anticipated, recognized and managed by the laparoscopic surgeon.

Case: A woman presented four years after a mesh and staple colposuspension for stress urinary incontinence with bladder pain and hematuria. A staple was seen under the urothelium in the bladder dome and it was removed cystoscopically with resolution of symptoms.

Conclusion: This is an avoidable complication of an increasingly performed procedure. Correction can be effected cystoscopically if the staple is visible. 

INTRODUCTION

In 2000 Sharpe¹ reported a case of erosion of staples into the bladder following a mesh and staple colposuspension.  In this case he removed the mesh and staples by laparotomy. While other cases have been related anecdotally, there has been little published regarding the complications unique to mesh and staple laparoscopic repairs for stress urinary incontinence. This is a report of one such complication from a total of 68 cases. 

CASE REPORT

The patient is a 70-year-old woman who underwent a laparoscopic mesh and staple colposuspension performed in 1996 for stress urinary incontinence. The procedure was performed by the technique described by Ou².  The operation failed within a few months and her incontinence returned.  She underwent a second repair using the open technique of suprapubic urethral suspension but the mesh and staples from the failed laparoscopic approach were not removed. After the second procedure she remained continent and had no problems for approximately four years. 

Late in 1999, she fell and struck her abdomen but did not require medical intervention.  Shortly after the fall, she began to experience suprapubic pain that was continuous but worsened with bladder distension and with micturation.  She had persistent microscopic hematuria but urine cultures were consistently negative. An office cystoscopy was performed and a staple was noted beneath the urothelium at 2 o’clock in the bladder dome. She had pain in the area lateral to the bladder neck with digital vaginal palpation.  Under general anesthesia two helical staples were removed using cystoscopic grasping forceps. The staples were lodged partially beneath the bladder epithelium in the muscularis. These were the only staples seen on cystoscopy. At the time of operation, the decision was made only to remove the staples that were visible cystoscopically and not to explore the space of Retzius.    She wore a Foley catheter for three days. She had persistent bladder spasms for ten days, which were treated with hyoscamine and methylene blue tablets. Her continence was not impaired. Following recuperation her pain was completely relieved.

DISCUSSION

Over the last 5 years we have performed 51 laparoscopic mesh and staple colposuspensions. Forty-six are reported in a case series which is presently in review for publication³. An additional 17 procedures were performed with the mesh and staple technique by laparotomy. In each case, before removing the laparoscope from the abdomen, cystoscopy was done to confirm ureteral patency and look for bladder injury. When staples were seen piercing the bladder wall they were removed, usually laparoscopically.  Staples lodged in the muscularis but not penetrating the urothelium, of course, would not have been seen and removed. To date this is the only case in which the patient has had symptoms related to erosion of a staple necessitating evaluation and removal.  It seems likely that the staples were placed in the bladder wall, when the bladder was deflated but was not retracted far enough medially. While stapling the mesh to the pubovesicocervical fascia adjacent to the bladder neck, it would certainly be easy to fail to recognize the edge of the bladder and include it in the stapling.   In this case, it seems probable that the staples were originally placed in the muscularis, just under the urothelium. After the patient’s fall, or possibly just coincident with it, the erosion or migration of the staples became symptomatic. The malplacement of the staples may well be related to the failure of the original operation to restore her urinary continence.  If the staples had not been visible cystoscopically, it would have been necessary to re-explore the space of Retzius by laparoscopy or laparotomy to effect removal. In this case, the exact course of events is unclear but it seems likely that the staples were place into the bladder wall but not completely through the muscularis at the time of surgery. It is possible that her fall precipitated further erosion or migration of the staples causing her pain and hematuria.

When performing this reparative procedure, the surgeon should be aware of this possible complication at the time of surgery when the staple can be removed easily.  Furthermore, this reinforces the need to identify and retract the edge of the bladder before staple placement. Transillumination of the bladder by a light in the vagina might prove helpful.  This complication should also be considered in the evaluation of a patient who has undergone this type of surgical repair and later presents with bladder pain or dyspareunia. While all operations have complications, newer techniques require monitoring for previously unknown or unanticipated complications. Despite earlier isolated reports, the incidence or prevalence of this particular complication of the mesh and staple colposuspension remains unknown.  Nevertheless, recognition of this possible complication should aid the surgeon performing a laparoscopic mesh and staple colposuspension to avoid placing staples in the bladder and potentially improve the success of the procedure. 

REFERENCES

1.     Sharpe HT, Doucette R C, Norton P A, Journal Reprod Med 2000; 45:947-949

2.     Ou C, Presthus J, Beadle E. Laparoscopic Bladder Neck Suspension Using Hernia Mesh and Surgical Staples. J Laparoendoscopic Surg 1993; 3: 563-566.

3.     Washington J, Somers K., Laparoscopic Mesh and Staple Colposuspension. In review