eau-ebu update series 5 (2007) 232–240

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Managing Complications after Midurethral Sling for

Stress Urinary Incontinence

Elisabetta Costantini *, Massimo Lazzeri, Massimo Porena

Department of Medical-Surgical Specialties and Public Health, Section of Urology and Andrology, University of Perugia, Perugia, Italy

Article info Abstract

Keywords: Since Ulmsten and Petros’s original description of the tension-free

Complications vaginal tape (TVT) procedure in 1995, the midurethral sling (MUS) has
Midurethral sling become first-line therapy for correction of female stress urinary incon-
Stress urinary incontinence tinence (SUI). Cure rates are high for TVT and the recent tension-free
Therapy trans-obturator tape (TOT) procedures, and the incidence of side effects
is low. In the past few years although several studies have dealt with the
incidence and prevalence of MUS-related complications, their surgical
management remains an open issue. This paper presents the rationale
for surgical management of MUS-linked complications, updates pro-
gress in new strategies, and tracks translation of recommendations
on vaginal and urethral erosion, postoperative voiding difficulties, and
de novo urgency into clinical practice.
# 2007 European Association of Urology and European Board of Urology.
Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Medical-Surgical Specialties and Public Health,

Section of Urology and Andrology, Via Brunamonti 51, 06100 Perugia, Italy.
Tel. +39 075 5783198; Fax: +39 075 5726123.
E-mail address: ecostant@unipg.it (E. Costantini).

1. Introduction and improving the quality of care in SUI. Surgery for

Since Ulmsten and Petros’s original description in
1995 of the tension-free vaginal tape (TVT) proce-
dure [1] for female stress urinary incontinence (SUI)
many other techniques, materials, and approaches
have been described [2]. The safety and efficacy of
TVT and the more recent trans-obturator tape (TOT)
procedures have been extensively investigated [3],
but only a few reports have dealt with the true
incidence and prevalence of complications [4] and
even fewer with their management [5].
Urologists, gynaecologists, patients, health fund-
ing institutions, and health policy makers are
striving to identify specific indicators for assessing
1871-2592/$ – see front matter # 2007 European Association of Urology and European Board of Urology. doi:10.1016/j.eeus.2007.07.004
Published by Elsevier B.V. All rights reserved.
female pelvic organ prolapse (POP) and SUI must be
successful if quality of life (QOL) is to improve
because failure and complications may have devas-
tating effects on patients. Olsen et al reported that
women have an 11% lifetime risk of one operation
for POP or urinary incontinence; 29% of patients
who undergo surgery risk a second operation,
31% risk a third, 41% risk a fourth, and 67% risk a
fifth operation [6]. As risk rises with failure and
MUS-related complications, estimating their true
incidence and prevalence and quickly recognising
and managing them properly are key factors in
quality of care improvements in patients who
undergo surgery for SUI.
 eau-ebu update series 5 (2007) 232–240
This paper reviews the incidence and prevalence
of MUS-related complications and addresses the
rationale for their surgical management, updates
progress in new conservative and operative strate-
gies for treating complications, and tracks transla-
tion of recommendations about vaginal and urethral
erosion, postoperative voiding difficulties, and ex
novo urgency into clinical practice.
2. Definition and epidemiology of SUI
The International Continence Society defines SUI as
involuntary urine leakage on effort, exertion, sneez-
ing, or coughing and mixed urinary incontinence
(MUI) as involuntary leakage associated with urgency
(a sudden, compelling desire to pass urine, which is
difficult to defer), exertion, effort, sneezing, or
coughing (www.icsoffice.org).
The prevalence of urinary incontinence ranges
from 2% to 55%, depending on definition, type, data
collections, sex, and ethnic group. In community-
dwelling women it ranges from 10% to 40% but
reaches  50% in elderly women and in institution-
dwelling adults [7]. SUI is reported to account for 49%
of female urinary incontinence, urgency inconti-
nence for 22%, and MUI for 29%. The Norwegian
Epidemiology of Incontinence in the County of Nord-
Trondelag (EPINCONT) study reported a 4.7% inci-
dence of SUI in nulliparous women but noted it
increased to 12.2% in women who had undergone
vaginal delivery [8]. Although the prevalence of
urinary incontinence may be surprising to many
clinicians, women often underreport or delay seek-
ing treatment for several years after the problem has
become bothersome. Incontinence has a major
impact on QOL, which is often not appreciated by
health care providers [9]. Finally, complications after
surgery for SUI may drive QOL to a level below the
patient’s preoperative status.
3. Pathophysiology
Urologists and gynaecologists need to be aware that
many aspects of the mechanism of female con-
tinence are still not clear. Normal continence in
women is a complex coordination of the bladder,
urethra, pelvic muscles, and surrounding connec-
tive tissues. The urethra, a 3- to 4-cm long tube,
passes urine during the voiding phase of the
micturition reflex and maintains sufficient pressure
to prevent urine leakage during the storage phase or
during physiologic increases of abdominal pressure
such as coughing or physical activities. These two
233
functions depend on central, peripheral autonomic
(sympathetic and parasympathetic systems) and
somatic neuronal control and local peripheral
factors.
Pelvic muscles and ligaments also contribute to
urinary continence. Levator ani contraction pulls
the vagina forward toward the pubic symphysis,
creating a stable urinary tract backstop, which
compresses the urethral walls and prevents urine
leakage during coughing or similar intra-abdominal
pressure increases. Tissue connecting the urethra
and bladder neck to the vagina and pubic symphysis
supports and prevents leakage. In their ‘‘integral
theory’’ of female urinary incontinence, involving
different pelvic organs and the perineum, Petros and
Ulmsten [10] hypothesised that stress and urgency
incontinence both originate from vaginal laxity,
which may be caused by intrinsic defects within the
vagina wall itself, or to the ligaments, muscles, and
connective tissue insertions that constitute its
supporting structures. They concluded that the
vagina has a dual function: it mediates or transmits
muscle movements to the bladder neck, permitting
a valid opening and closure mechanism, and its
structure prevents urgency by supporting hypno-
tised stretch receptors at the proximal urethra and
bladder neck. Thus, altered collagen or elastin
content in vaginal tissue or in its ligaments might
cause SUI or activate uninhibited detrusor contrac-
tions.
Under normal conditions some of the afferent/
efferent signal pathways to and fro between the
lower urinary tract and higher neural centers, the
relationship between anatomic support and func-
tion, and the ability of the continence mechanism to
adapt and repair after childbirth or neurologic
injuries, also need to be considered. In women with
complications after MUS, urologists and gynaecol-
ogists also must factor in acute or chronic inflam-
mation status, sling materials, and the host–mesh
relationship.
SUI originates when, during sudden increases of
intra-abdominal forces, bladder pressure exceeds
urethral pressure. Urine leakage may derive from
loss of backstop support at the bladder neck
(bladder-neck hypermobility) or from intrinsic
sphincter defeat, that is, the loss of muscular tone
at rest, which is termed ‘‘low-pressure urethra’’ or
‘‘intrinsic sphincter deficiency.’’ In the TVT and TOT
era urologists learned that grouping patients into
these two dichotomous categories does not trans-
late into different therapeutic strategies. SUI varies
between the extremes of intrinsic sphincter defi-
ciency and bladder-neck hypermobility, with most
patients presenting both disorders.
234 eau-ebu update series 5 (2007) 232–240

In conclusion, SUI might be due to childbirth, Table 2 – Signs and symptoms of complications after
midurethral sling procedures
labor, and obstetric injuries to perineal muscles,
connective tissue, and nerves resulting in inability Complications Symptoms
to support the bladder neck. Vascular damage that
Obstruction Postvoid residue urine
might affect muscles and nerves, ageing, and risk Straining to void
factors such as obesity are major factors in the Incomplete bladder empty
pathogenesis of SUI. Urologists and gynaecologists Recurrent urinary tract infec-
tions
need to know that treating MUS-related complica-
Urgency
tions (ie, erosion) may result in a return to incon- Poor stream
tinence, which will be very difficult to ‘‘reconvert’’
Bladder erosion Haematuria
into urinary continence. Pain (suprapubic/urethra)
Infection

Vaginal erosion Pain

4. Complications Dyspareunia
Dysuria
Urinary tract infections
MUS procedures have gained popularity not only
Vaginal discharge
because success rates are high, but also because Vaginal bleeding
complication rates appear low. Major and minor
De novo urgency Frequency
complications remain, however, a discussion point Urgency
and a diagnostic and therapeutic challenge for even Nocturia
the most skilled urologist and gynaecologist. Table 1 Urgency incontinence
presents the percentage range of complications after Urethral erosion Pain
MUS procedures, according to reports; Table 2 sum- Urethral bleeding
marises the main symptoms of early and late Urethral discharge
Infections
complications; and Table 3 describes the aetiology Urgency
of complications. Poor stream
Several variables have an impact on the epide-
miology of MUS-related complications. Lack of
worldwide national registers of all MUS procedures complications; a discrepancy exists between com-
means that often investigators do not have the plication rates in scientific reports and independent
denominator for calculating the true incidence of databases such as the Manufacturer and User Facility
Device Experience (MAUDE), which monitors volun-
tary reporting of MUS-related complications. Deng
Table 1 – Complications after midurethral sling et al recently investigated the incidence of major
procedures MUS-related complications in the American popula-
Intraoperative tion and found they were underreported. A signifi-
Major cant discrepancy emerged between scientific reports
Vascular lesions < 0.01% in English and Food and Drug Administration (FDA)/
Nerve injuries < 0.0005%
MAUDE reports, which collected four times as many
Gut lesions < 0.007%
Minor major complications [4]. The impressive paucity
Bladder injury 0.5–14% of major complications in reports gave a false sense
Repeated bladder injury 1.2% of security. Several explanations may be found:
Perioperative (1) reports may understate complications, (2) sur-
Retropubic haematoma 2–4.3% geons who have higher complication rates do not
Blood loss > 200 ml 2.7–3.3%
answer questionnaires, (3) differences exist between
Urinary tract infections 10%
Spondylitis 0.3–0.8% high- and low-volume surgeons, and (4) under-
reporting or over-reporting complication rates might
Postoperative
Transient urinary retention 1.4–15% be accounted for by surgeons who manage the
Permanent urinary retention 2.4–2.8% complications.
Vaginal erosion 0.7–33% Another issue is timing of complications. Ham-
Urethral erosion 2.7–33%
mad et al [11] reported that 35% of vaginal erosions
De novo urgency 7.2–25%
Bladder erosion 0.5–0.6%
were asymptomatic and erosion was discovered on
Urethral obstruction 3.6–6.4% routine follow-up, not during a symptom check-up.
Kobashi et al seemed to confirm these data. In > 90
Ranges are as reported in the literature.
women who received a polypropylene mesh for the
 eau-ebu update series 5 (2007) 232–240
Table 3 – Aetiology of midurethral sling-related
complications
Complications Aetiology
Vaginal erosion Inadequate suturing of vaginal
wall
Extensive dissection
Early resumption of sexual ac-
tivity
Previous vaginal surgery
Wound infection
Incorrect vaginal plane
Rolling of the tape
Ischaemia
Urethral erosion Excessive tension
Ischaemia
Extensive dissection around ure-
thra
Previous surgery
Infection
Incorrect plane of dissection
Rolling of the tape
Bladder perforation Operative technique
treatment of SUI, 3 developed vaginal erosion, but
only 1 had symptoms such as pain, discomfort
during sexual activity, and vaginal discharge and
erosion was discovered during a routine check-up
[12]. Similar data were also reported for urethral
erosion, even though the percentage of asympto-
matic erosion was 11%. Generally, however, 66% of
whole erosion is discovered within the first 3 mo
after surgery. Urologists and gynaecologist must be
aware that in a high percentage of cases signs and
symptoms of complications often begin early after
surgery and the surgeon needs to understand and
recognise them to offer the best treatment as soon
as possible.
Performance of new surgical tasks improves with
experience over time. This learning curve presents
particular difficulties in the modern health technol-
ogy era [13]. Many surgeons who apply new minimal
access approaches are often reluctant to apply
rigorous evaluation to a new procedure whose
outcome and complication rates may change with
learning curves [14]. In MUS a study of the learning
curves might allow adjustments to be made to
earlier assessments of complications. In an analysis
of the complication rate in 140 female patients who
underwent the suprapubic arc (SPARC) operation for
SUI [15], Kobashi et al found timing of complications
did not seem to correlate with learning curves and
concluded complications were probably more inher-
ent to technique than a reflection of experience.
Comorbidities have been reported to increase the
incidence of complications. Boyles et al [16] showed
that comorbidities, such as diabetes and vascular
235
diseases, were associated with a 2-fold increase in
the risk of major (but not minor) complications
(sepsis, pulmonary failure, thromboembolic events,
and myocardial infarction). Obesity (body mass
index [BMI]  35 kg/m2) might increase technical
difficulty and complication rates. In 43 obese
patients and 35 matched, nonobese women who
were treated with TVT, Lovatsis et al [17] observed
that obesity did not increase the risk of local
complications. On the other hand, Skriapas et al
[18] found deep vein thrombosis, arrhythmia, and
pneumonia were more frequent in obese patients.
Another important comorbidity, which could
increase the risk of local complications, is earlier
radiation for gynaecologic cancers.
Bleeding is another issue. Data from a national
registry of 5578 patients who underwent TVT,
reported 151 patients (2.7%) suffered from bleeding
and 45 patients required reintervention or proce-
dure conversion [19]. Suprapubic ultrasound in 31
asymptomatic patients after TVT visualised hae-
matomas > 5 cm in 16% [20].
Another open question is whether TOT is asso-
ciated with fewer complications than retropubic
slings. Laurikainen et al [21] reported that patients
who underwent TVT-O had a significantly longer
hospital stay, needed significantly more postopera-
tive opiate analgesia, and had significantly more
complications than patients in the TVT group, but
these significantly higher complication rates were
not regarded as clinically significant. Zullo et al [22]
recently reached the opposite conclusion. Perio-
perative complications were significantly more
common after the retropubic approach (5% and
27% in TVT-O and TVT groups, respectively,
p < 0.04); TVT-O had a shorter operating time and
lower overall perioperative complication rates. TVT,
however, seems to be associated with a higher
obstructive voiding dysfunction, with an incidence
ranging from 17% to 50%, and its treatment remains
one of the main challenges for urologists and
gynaecologists. Boyles et al [23] analysed complica-
tions associated with TOT slings as reported in the
MAUDE register, a national US database that collects
reports of complications associated with medical
devices, which is maintained by the FDA. Previously
unreported complications, such as obturator nerve
injuries, large blood loss ( 600 cc), and ischiorectal
fossa abscesses were associated with different,
commercially available trans-obturator slings.
Another important concern is emergence of ex
novo urgency after anti-incontinence sling place-
ment. In a multivariate analysis, Botros et al [24]
found TOT was associated with less ex novo urgency
and urge urinary incontinence (UUI). It significantly
236 eau-ebu update series 5 (2007) 232–240

increased the chance of resolving preoperative UUI
compared with retropubic procedures; UUI symp-
toms worsened in 6% of subjects after TOT com-
pared with 14–16% after TVT/SPARC. The hypothesis
that tape location closer to the bladder neck
correlated with a higher risk of voiding dysfunction
or complications was not confirmed. Voiding dys-
function is more likely to occur if the tape is too
tight, that is, too close to the urethra. Ultrasound
studies have demonstrated midurethral tape posi-
tion in 85.7% of patients. Variations in tape place-
ment seemed to have little effect on symptoms.
Finally, sling material plays a fundamental role in
the genesis and management of complications.
Several papers have reviewed this topic and
Tables 4 and 5 summarise the characteristics and
the pros and cons of different materials [25]. Gen-
erally speaking synthetic nonabsorbable materials

Table 4 – Pros and cons of substitution materials depending on their origin

Mesh Categories Material Brand name Pros Cons

Synthetic Absorbable Polyglactin acid Vicryl Low risk of erosion Poor scar formation
Low risk of infection Poor tensile strength
High failure rate
Polyglycolic acid Dexon Low risk of erosion Poor scar formation
Low risk of infection Poor tensile strength
High failure rate
Nonabsorbable Polypropylene Prolene Large size pores Tissue fixity
(1500 mm)
Flexible Scars
Lower risk of erosion
High tissue conformity
Marlex Smaller size pores Erosion
(600 mm)
Polyester Dacron High resistance (strong) Fray
Good memory Poor tissue
conforming
InteMesh Erosion
(silicone-coated)
Protogen High erosion rate
(recalled in 1999)
Silicone Silastic Smoother High host rejection
Increase the Fibrous Poor long-term
sheath resistance
Polytetrafluoroethylene Gore-Tex Erosion
Polyethylene Mersilene Inflammatory
terephthalate reaction

Nonsynthetic Autograft Rectus fascia Naı̈ve tissue Patients’ morbidity

Easy to harvest Recovery time
Durable Increase collagen
synthesis
Sling contraction
Fibroblast penetration
Fascia lata Long specimens Higher operative time
Uniform in thickness Infection
Avoids abdomen Collagen degradation
incision
Allograft Cadaveric fascia lata Tutoplast Low patient morbidity Prion and virus
infection
Alloderm Low operative time Rejection
Cadaveric dermis Low patient morbidity Prion and virus
transmission
Low operative time Rejection
Low erosion rate
Xenograft Porcine tissue Dermis (Derm-Matrix, High tensile strength Prion and virus
Pelvicol, Pelvisoft) High biocompatibility transmission
Small intestine High tensile strength Prion and virus
submucosa (Surgisis) High biocompatibility transmission
Bovine tissue Dermis (Xenform)
Pericardium (Peri-guard,
Veritas, Uropatch)
 eau-ebu update series 5 (2007) 232–240
Table 5 – Pore size classification of mesh
Type 1 Large-sized pores (> 75 mm)
It allows admission of macrophages and ingrowth
of fibroblasts (fibroplasias) blood vessels
(angiogenesis) and collagen.
Type 2 Medium-sized pores (10 mm)
It has a structure, which does not permit the
immunocell migration; it is encapsulated by
host tissue.
Type 3 Large- and medium-sized pores
It has a complex structure including large- and
medium-sized pores and it includes multifilament
material.
Type 4 Small size pores (< 1 mm)
Not used as mesh.
are plagued with a higher incidence of erosion,
infection, and fistula. Comiter et al reported that
the urethral erosion rate might be 10 times greater
with synthetic materials than with organic slings [26].
Woven materials are claimed to have greater com-
plication rates than nonwoven materials. Multifila-
ment tapes may increase the risk of infection and
vaginal erosion. Micropore multifilaments, which
are more flexible, less extensible, and easier to
adjust, may be associated with a lower incidence of
obstruction [27]. Polypropylene tends to have a lower
complication rate (0–5%) than polytetrafluoroethy-
lene (Gore-Tex), polyester (Dacron), or silicone (4–
30%). The efficacy of a polypropylene MUS in
restoring continence depends on its biomechanical
properties before and after implantation. Complica-
tions, such as erosion and infection, which are due to
local inflammatory reactions, reflect its ‘‘biocompat-
ibility’’ (Table 6). A sling’s biologic characteristics,
that is, how well it incorporates within native tissue,
is the main factor predicting erosion [2].
5. Treatment of complications
Mesh erosion, one of the most frequent complica-
tions, can be managed with conservative or non-
conservative strategy, depending on the erosion site
Table 6 – Biocompatibility of polypropylene mesh
Brand Inflammatory
infiltrate
Advantage monofilament type 1 Moderate
IVS multifilament type 3 Moderate
SPARC monofilament type 1 Extensive
TVT monofilament type 1 Low
IVS = intravaginal slingplasty; SPARC = suprapubic arc; TVT = tension-free vaginal tape.
TVT has the highest biocompatibility. Inflammatory infiltrate and fibrosis are considered parameters of rejection.
237
and extension, mesh material, and patient’s clinical
status. Oestrogen therapy in small vaginal erosion
may favour spontaneous healing or prepare the
vagina for surgical repair. However, in women
receiving oestrogen therapy, mesh erosion increased
when hysterectomy was associated with sacral
colpopexy [28]. Surgical approach ranges from par-
tial, simple excision of the exposed mesh to surgical
exploration for total graft removal and tissue recon-
struction with a Martius flap. According some
authors, polypropylene tape erosion should be
treated with complete mesh removal, without regard
to erosion site, width, or local tissue condition [29].
Explantation is recommended when erosion involves
the lower urinary tract (bladder or urethra), inde-
pendently of sling materials [30,31]. Vaginal erosion
of synthetic materials, such as polyester and silicone
slings, should also be treated with mesh removal
because epithelialisation over these materials is
unlikely [12,31,32]. However, when erosion is limited
to the vagina, conservative management with obser-
vation might be a viable option [31] if the sling were
made of autologous, allograft and new, loosely woven
polypropylene material because the latter provides
large interstices, which favour tissue ingrowth and
healing. Furthermore, the self-fixing nature of poly-
propylene may allow the graft to integrate into
surrounding tissues without other complications,
which could occur more frequently with tightly
woven meshes. When a conservative approach is
scheduled two questions remain. How long should
one reasonably wait for epithelialisation and what is
the maximal area of sling exposure to consider for
conservative management? Kobashi et al suggested
that when the vaginal epithelium appears to cover
the mesh but has not completely grown over all of it,
further observation might be considered rather than
sling removal. Up to approximately 1 cm of mesh
exposure should become epithelialised within 6 wk;
larger exposed areas could become epithelialised
after a longer observation period [12]. Consequently,
when the erosion involves the vagina and is  1 cm,
one should preserve the sling. If no starting or partial
Fibrosis Muscular Mast cell Collagen
infiltration presence filling
Extensive Extensive High Minimal (< 25%)
Moderate Moderate Low Partial (25–50%)
Extensive Extensive High Minimal (25%)
Very low Low Moderate High (> 50%)
238 eau-ebu update series 5 (2007) 232–240
overgrowth is evident by 3 mo postoperatively,
sling removal should be seriously considered.
When one decides to adopt a conservative strategy
for sling erosion, the patients need careful counsel-
ling about the risks, benefits, and alternatives.
Patients must be informed of the ideal outcome of
sling preservation versus the opposite scenario of
failure of the sling to epithelialise despite prolonged
abstinence from intercourse. A wound-healing vagi-
nal defect may be a challenging complication,
particularly in obese, diabetic, or immunocompro-
mised patients. Because chronic tape inflammation
is the main cause of disturbed wound healing, vaginal
resection of the periurethral parts of the tape is
mandatory.
Ex novo urgency, although claimed to be the
complication with the strongest negative impact on
QOL, is sometimes self-limiting. When a patient
complains of urgency after surgery, the surgeon
must rule out and remove specific causes of
urgency, such as urethral erosion, intravesical tape,
urinary retention, or recurrent urinary tract infec-
tions. If urgency and UUI persist, oral antimuscari-
nic agents are first-line therapies. Should they fail,
alternatives (intravesical vanilloids, intradetrusor
injection of botulinum toxin, and sacral neuromo-
dulation) may be proposed.
Postoperative obstruction is another challenging
complication. Early postoperative transient urinary
retention, which may require intermittent sterile
self-catheterisation, tends to resolve within 12 wk
with restoration of complete bladder emptying
in the majority of cases. If urinary retention or
subvesical obstruction with high postvoid residual
volume persists after 12 wk and is due to excessively
tight mesh, tape transvaginal urethrolysis may be
performed. Klutke et al described suburethral tape
transaction under local anaesthesia without further
resection and mesh release without transaction for
treating persistent postoperative urinary retention
[5]. In this series, 16 of 17 patients treated with either
technique voided completely after therapy and
remained continent and the other patient with
intraoperative urethral damage needed a further
reconstruction. Volkmer et al [33] confirmed these
data, reporting that patients with obstruction
remained continent after sling transaction and
suggesting periurethral sling resection could destroy
the scars that replaced the urethropubic ligaments
and could lead to urinary incontinence. Few (0.6% of
9040 patients) need tape transaction for persistent
urinary retention [34]. SUI recurrence after tape
release remains an open issue and at present there is
no consensus on severity, voiding dysfunction
duration, and timing of tape release. Professional
experience and the patient’s clinical status should
guide decisions on timing.
Bladder perforation is a perioperative complica-
tion that has been described as prevalent after TVT.
Bladder perforation usually does not need any
further therapy except catheter drainage for 2–4 d.
Bladder erosion that is not evident at cystoscopy but
emerges weeks later is due to submucosally placed
tape with secondary erosion. Polypropylene mesh
contact with urine always leads to tape incrustation
without any possibility of correcting the tape
position so the mesh must be removed. The earlier
a misplaced tape is explanted, the fewer the scars,
the less inflammation that will develop, and the
easier complete removal will be [2]. In selected,
complicated cased, that is, associated with stones,
bleeding, or recurrent infection, an open suprapubic
approach with cystotomy is recommended to
ensure access to the intravesical parts of the tape.
Surgical evacuation of Retzius haematoma is rare.
Bleeding usually originates from pelvic floor veins or
epigastric vessels and evacuation is decided on
the basis of the patient’s clinical condition. Case
reports have described more severe complications
that required immediate surgical intervention, such
as perforation of the small intestine [35], external iliac
vein [36], or obturator nerve [37]. Although the risk of
such extraordinary injuries remains low, it is impor-
tant to keep them in mind. Finally, other case reports
showed obturator abscess, perineal and tight abscess,
and necrotising fascitis, which required specific
antibiotic therapy and eventually surgical drainage.
6. Conclusion
Minimally invasive treatment of SUI is not entirely
free of severe, long-lasting complications. A close,
long-term follow-up is paramount for improving the
patients’ QOL. Physicians who evaluate women
presenting with complications after they have had
a surgical procedure for SUI need excellent clinical
skills in the medical and surgical management of all
MUS-related adverse effects.
Acknowledgement
The authors would like to thank Dr Geraldine
A. Boyd for editing this paper.
Conflicts of interest
The authors have nothing to disclose.
 eau-ebu update series 5 (2007) 232–240
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CME questions
Please visit www.eu-acme.org/europeanurology
to answer these CME questions on-line. The CME
credits will then be attributed automatically.
1. What is a woman’s lifetime risk of a second
operation after a surgery for correction of pelvic
organ prolapse or urinary incontinence?
A. 15%
B. 19%
C. 29%
D. 54%
2. The theory of ‘‘integral therapy’’ states that
A. Both stress and urgency incontinence may be
due to vaginal laxity caused by defects within
the vaginal wall or its supporting structures,
for example, ligaments, muscles, and con-
nective tissue.
B. Stress but not urge incontinence may be due to
vaginal laxity caused by defects within the
vaginal wall or its supporting structures, for
example, ligaments, muscles, and connective
tissue insertions.
C. Urge incontinence but not stress urinary
incontinence may be due to vaginal laxity
caused by defects within the vaginal wall or its
supporting structures, for example, ligaments,
muscles, and connective tissue.
D. Both stress and urgency incontinence may be
due to neuronal control failure, which is
[36] Primicerio M, De Matteis G, Montanino Oliva M, et al. Use
of the TVT (tension-free vaginal tape) in the treatment of
female urinary stress incontinence. Preliminary results.
Minerva Ginecol 1999;51:355–8.
[37] Meschia M, Pifarotti P, Bernasconi F, et al. Tension-free
vaginal tape: analysis of outcomes and complications in
404 stress incontinent women. Int Urogynecol J Pelvic
Floor Dysfunct Suppl 2001;12:S24–7.
responsible for functional integration of pelvic
organs.
3. Obesity increases the risk of
A. Vaginal and/or urethral erosion.
B. Ex novo urgency.
C. Urinary tract infection.
D. Deep vein thrombosis.
4. The management of erosion involving the urinary
tract is
A. Explantation of all sling materials.
B. Oestrogen plus antibiotic therapy.
C. Placement of suprapubic catheter and anti-
biotic therapy.
D. Suturing erosion edges.
5. In vaginal erosion slings made of which materials
have to be removed?
A. Autologous.
B. Polyester.
C. Allograft.
D. Loosely woven polypropylene.
6. What percentage of patients require tape release
because of persistent urinary retention?
A. 0.6%
B. 3.2%
C. 4.5%
D. 7.8%