Complications of TVT
Apr 2011 – by F. Ling, MD
The tension-free transvaginal tape (TVT), a polypropylene mesh tape, was designed to treat stress urinary incontinence (SUI) resulting from urethral hypermobility and/or intrinsic sphincter deficiency. The tape provides support to the patient's own tissue without the use of a graft, thereby eliminating potential morbidity from the harvesting procedure. If the patient is not under general anesthesia, an intra-operative individualized adjustment of the tape can be accomplished whereby the patient is asked to cough, thereby simulating the stress that led to incontinence prior to surgery. With cure rates estimated at up to 90% in some series, the procedure is considered comparable to the Burch urethropexy.
Three incisions are made, one in the vaginal mucosa beneath the mid-urethra, and 2 in the abdominal wall, 1 cm. in length 2 cm. on either side of the midline above the symphysis pubis. It is through the vaginal incision that the needles are passed to either abdominal incision. The mesh tape attached to the needles is thereby drawn up to both incisions providing a sling-like support below the mid-urethra. Cystoscopic evaluation is needed after passage of each needle to document that bladder perforation has not occurred. Positioning a blunt instrument between the urethra and the tape while finalizing the position of the tape helps to avoid obstruction of the urethra. This creates a small space between the urethra and the tape, thereby establishing the TVT as a support for the urethra when it descends with increased intra-abdominal pressure.
Postoperatively, the patient is encouraged to avoid coitus and heavy lifting for at least a month. Other normal activities may be resumed in 1-2 weeks.
As with any operation, complications are possible. The peri-operative complications include bladder perforation, injury to adjacent structures such as bowel, nerves, and blood vessels, and even death. Postoperative complications include urinary retention, urinary urgency, urinary tract infections, hematomas, wound complications, erosion into bladder and/or vagina, infection, vesico-vaginal fistula, and lack of desired symptomatic outcome.
The primary intra-operative problem is bladder perforation. This occurs in approximately 2% of cases. The use of cystoscopy is critical in diagnosing this problem intra-operatively. Should bladder perforation be identified, re-insertion may be attempted with direction of the needle insertion being more lateral. It is generally recommended that after no more than three attempts on either side, another surgical option should be pursued. The use of the rigid sheath inserted within the Foley catheter is also used to manipulate the position of the bladder and urethra to minimize the risk of bladder perforation. Should bladder perforation occur, Foley catheter drainage is recommended for at least 24 hours and antibiotics may be indicated. This is in addition to the prophylactic antibiotics that she should have received pre-operatively. One possible way to minimize this risk is proper patient selection. Patients who have had previous retropubic procedures may have significant scarring, making this blind procedure more risky due to distorted anatomy.
A second significant complication can be post-operative voiding problems. If the patient does not void immediately, Foley catheter drainage for 48-72 hours is recommended. The presumed obstruction of the urethra being caused by a TVT that is too tight can be addressed by inserting a Hegar dilator into the urethra and applying pressure downward to loosen the tape. It should be noted that the mechanism of action here is not dilating of the urethra, but of reducing the tension of the tape beneath the urethra. During the next several days, should voiding problems occur, the vaginal incision can be opened and the tape grasped with a clamp. Traction downward half a centimeter or thereabouts can relieve the obstructive symptoms.
Addressing voiding problems after the first 10 days or so post-op may involve delay of intervention until the patient is approximately a month out from surgery. This allows the tissue to heal and the tape to become fixed in its position. During this interval, self-catheterization is performed by the patient. Then, a vaginal incision allows access to the tape. Dividing of the tape at this time should allow relief of the obstruction symptoms with preservation of continence.
A third possible complication is urgency or urge incontinence. This is true with any incontinence procedure, but can be associated with positioning of the tape near the bladder neck rather than at the mid-urethral position. Bladder re-training and/or anti-cholinergic medications may be used in these cases.
A fourth possible complication is infection of the TVT. Although rare, it should still be a consideration, particularly for patients with pain and/or fever. Should it occur, however, and antibiotic therapy not prove effective, removal of the tape may be necessary.
A fifth potential complication, bleeding, is also an infrequent event. Less than 3% of patients have this problem, with most being intra-operative. This can be due to either venous or arterial causes. Post-operative hematomas can usually be managed conservatively.
A sixth complication is that of erosion, either into the bladder or the vagina. This can occur despite appropriate intra-operative placement. Bladder erosion may present with hematuria, recurrent urinary tract infections and/or urinary symptoms. Vaginal erosion symptoms include pelvic pain, discharge, and dyspareunia. Management is likely to include excision of the tape although conservative management is sometimes successful.
Finally, failure of the procedure should always be discussed with the patient. Avoiding this complication involves both proper patient selection and operative experience of the surgeon. Certainly, patients should be properly evaluated as to the cause of their incontinence before the TVT or any procedure is performed. Patients with previous incontinence procedures may be more challenging for the TVT since it is a blind insertion of the mesh. Other patients who are not appropriate candidates for TVT are those who are pregnant or are potentially going to be pregnant.