Urogynecology: Case Report
Obturator Neuropathy After Retropubic Tension-Free Vaginal Tape Placement Aparna Ramanathan, MD, Stefanie Bryant, MD, T. Ignacio Montoya, MD, and Clifford Y. Wai, MD BACKGROUND: We report a case of obturator neuropathy associated with retropubic midurethral sling. CASE: After retropubic tension-free vaginal tape (TVT) placement, a 36-year-old woman reported right inguinal region and thigh pain, both exacerbated with internal rotation and adduction. Neurologic examination was remarkable for two-fifths strength with right thigh adduction and an involuntary lateral drift of her right thigh with straight leg raise. Radiologic evaluation was unrevealing. With persistence of motor symptoms and pain, partial sling removal on the right was performed. Symptoms subsided postoperatively, and the patient ultimately recovered with no residual neurologic sequelae. CONCLUSION: Recognition of an atypical complication, obturator neuropathy, of retropubic TVT placement with prompt partial right sling removal on postoperative day 2 resulted in complete recovery of neurologic sequelae. (Obstet Gynecol 2015;125:62–4) DOI: 10.1097/AOG.0000000000000594
M
idurethral slings, especially the tension-free vaginal tape (TVT), have become a mainstay for the treatment of stress urinary incontinence (SUI). The procedure has demonstrated efficacy and durability1,2 with generally low rates of complications that include: hemorrhage (2–5%), bladder injury (5%), urinary retention (2–3%), and urinary tract infection (5–8%).3 From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas. Corresponding author: Clifford Y. Wai, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9032; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
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Teaching Points 1. All mechanisms of neurologic injury should be considered when neuropathy occurs after retropubic placement of a midurethral sling. 2. Partial removal of tension-free vaginal tape in the immediate postoperative period can result in resolution of significant pain and motor symptoms related to the procedure with maintenance of continence.
Neuropathy is a documented complication of transobturator midurethral slings but is less so with a retropubic approach, with rates of 0.3% and 1%, respectively.3 We describe a rare case of obturator neuropathy associated with retropubic TVT.
CASE A 36-year-old healthy multiparous woman with normal body mass index was scheduled for surgery at a universitybased teaching hospital for the bothersome stress component of her mixed urinary incontinence. She had an unremarkable surgical history except for a prior bilateral tubal ligation. She had no symptoms of prolapse nor report of urinary retention. Aside from urodynamic stress incontinence the urodynamic evaluation was unremarkable, with normal capacity, normal flow rate, detrusor void, no detrusor overactivity, and a nonelevated postvoid residual. The patient underwent retropubic TVT (Gynecare TVT) placement with cystourethroscopy. The trocar on the patient’s left was placed without incident. With the right trocar, some brisk bleeding was encountered that abated with some vaginal pressure; otherwise, placement was unremarkable. The total estimated blood loss for the procedure was 100 mL. Cystourethroscopic survey after each trocar passage demonstrated no injury to the bladder or the urethra. In the postanesthesia care unit, the patient reported muscle cramping in the right inguinal region and thigh, both of which were exacerbated by internal rotation and adduction. She was unable to bear weight on the right and needed assistance to ambulate to the restroom. Although injury from trocar placement was entertained as a working diagnosis, neurologic injury from patient positioning and expanding hematoma in the retropubic space were also part of the differential diagnosis. A stat hematocrit level was 29.6 g/dL (decreased from a preoperative value of 38.4 g/dL), and the patient was hemodynamically stable. However, given the presentation and severity of the symptoms, the patient was admitted for further observation, serial hematocrit assessments (which stabilized at 27.1 g/dL), and diagnostic evaluation. On postoperative day one, the patient reported slight interval improvement in discomfort and mobility but had persistence of neurologic symptoms, with moderate pain
OBSTETRICS & GYNECOLOGY
associated with right thigh adduction but none at rest. She also denied any sensory deficits. Notable neurologic examination findings included two out of five strength with right thigh adduction and an involuntary lateral drift of her right thigh with straight leg raise—distributions highly suggestive of obturator nerve involvement. The physical therapy department was consulted for evaluation; they concurred with obturator neuropathy and initiated exercise therapy and occupational health recommendations. An abdominal and pelvic computed tomography scan was obtained and ruled out presence of a hematoma, with no other significant findings. With the elimination of compression by hematoma as a diagnosis coupled with continued weakness with thigh adduction, neuropathy from trocar placement remained as the main diagnosis. The patient was taken back to the operating room and underwent right partial sling removal on postoperative day 2. The suture of the original suburethral midline incision was cut and opened to access and isolate the sling. The sling then was transected on the right ;3 cm lateral to the midline incision of the vagina, and the remaining portion of mesh extending into the right periurethral tunnel was removed easily, along with 75 mL of clot. The incision was closed with 2-0 delayed absorbable suture. The day after partial sling removal, the patient reported moderate improvement in right thigh adduction and significantly decreased pain. Owing to the incomplete resolution of symptoms, albeit mild, the neurology department was consulted; they recommended a nerve conduction study and electromyography 2 weeks postoperatively to assess for muscle denervation. The patient continued to show improvement in both pain symptoms and strength and was able to ambulate easily with very minimal assistance from a walker. She was discharged home with a prednisone taper and outpatient physical therapy. Over the subsequent 2 weeks, the patient had further improvement in pain and strength, with complete resolution of symptoms 3 months after partial sling release. The patient was monitored in the urogynecology clinic for
a year and a half and has had no residual motor deficits nor neuropathic symptoms. A nerve conduction study using patch electrodes of the right lower extremity was normal. The patient declined the needle electromyography portion of the testing, citing complete recovery and no residual motor deficits. She has had good control of urgency incontinence symptoms with anticholinergic medication use. She denies recurrence of bothersome SUI symptoms and, on examination, has not leaked with cough stress testing.
DISCUSSION Neurologic injury is a debilitating condition and has a clinical presentation that can involve altered sensation, pain, and motor deficits. Cases of neuropathy after midurethral slings are rare, with only a few reports in the literature. One report details the transient effects of local anesthesia on the obturator nerve during placement of a transobturator sling.4 Another describes symptoms resulting from the obturator nerve encircled by a tape also placed by a transobturator route.5 Removal of the sling led to ultimate resolution of neurologic symptoms. Other reports describe ilioinguinal pain6 and perineal pain7 with a retropubic midurethral sling. Our report illustrates a rare case of obturator neuropathy occurring after retropubic midurethral sling placement. Although hemorrhage, bowel and bladder injury, and urinary tract infection all have been reported with retropubic TVT midurethral slings, obturator neuropathy is not a typical complication that has been reported. Given the trajectory of the retropubic midurethral sling trocar (as opposed to a transobturator technique), one may not reflexively entertain obturator nerve injury as high on the differential diagnosis. However, it is important to
Fig. 1. Retropubic view of right obturator internus muscle and obturator neurovascular bundle in a cadaver specimen. A. Normal trajectory of tension-free vaginal tape (TVT) trocar. B. Lateral rotation and cephalic deviation (white arrow) of TVT trocar with the tip in close proximity to obturator neurovascular bundle. Dotted line represents normal trajectory of trocar. PS, pubic symphysis; ObNVB, obturator neurovascular bundle; OBIntM, right obturator internus muscle. Ramanathan. Obturator Neuropathy After TVT Placement. Obstet Gynecol 2015.
VOL. 125, NO. 1, JANUARY 2015
Ramanathan et al
Obturator Neuropathy After TVT Placement
63
remember that all possibilities and mechanisms of injury always should be considered. An anatomical study by Abbas Shobeiri and coinvestigators provide some insight into a possible mechanism of injury.8 In their study, they determined the proximity of pertinent anatomic landmarks to the trajectory of the TVT, as well as other anatomic structures that could be involved if the trocar deviated from the normal path. We, thus, theorize that there may have been lateral and cephalic excursion of the trocar bringing the tip close to the obturator neurovascular bundle. A file photograph, previously taken in the anatomy lab of our fellowship training program, of a cadaver specimen with a retropubic midurethral sling placed illustrates a normal trajectory and a lateral and cephalic deviation of the trocar (Fig. 1). Alternatively, the trocar may have deviated lower and laterally and caught part of the obturator internus muscle, leading to possible traction on the obturator nerve or obturator internus muscle. Deviation of the trocar tip can occur from failure to retain a firm hold on the trocar handle during sling placement, with resultant axial rotation of the needle tip laterally. Needless to say, one always should be cautious of straying of the trocar and, if noted, one can either redirect it or stop, remove, and replace it if necessary. In this current case, symptom presentation was striking and persistent, and the evaluation was unrevealing for the common, less severe complications generally associated with the procedure. Elimination of these from the differential diagnosis was equally important in the diagnostic workup of this patient and, in our opinion, obligatory given the acuity and persistence of symptoms. Early recognition of the symptoms, with prompt, directed removal of part or all of the sling is a mandate in such a case. Additionally, we recommend a comprehensive and timesensitive approach to evaluation of neurologic signs and symptoms after sling placement, judicious involvement of multidisciplinary input and implementation of recommendations, and early recognition
64
Ramanathan et al
with appropriate therapeutic intervention. Although there is a role for conservative treatment, especially in cases of only mild sensory complaints, we believe that operative management is warranted in instances of significant motor deficits accompanied by moderate to severe pain, given the potential for permanent nerve damage. This report illustrates that prompt recognition of an uncommon and unpredictable neuropathy during midurethral sling placement in a teaching hospital, with expeditious intervention, can, fortunately, result in complete resolution of neurologic sequelae with maintenance of continence. All mechanisms of injury should be considered in an atypical presentation despite an unremarkable intraoperative course. REFERENCES 1. Nilsson CG, Palva K, Aarnio R, Morcos E, Falconer C. Seventeen years’ follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence. Int Urogynecol J 2013;24: 1265–9. 2. Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al. Retropubic versus transobturator midurethral slings stress incontinence. N Engl J Med 2010; 362:2066–76. 3. Brubaker L, Norton PA, Albo ME, Chai TC, Dandreo KJ, Lloyd KL, et al. Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study. Am J Obstet Gynecol 2011;205:498.e1–6. 4. Park AJ, Fisch JM, Walters MD. Transient obturator neuropathy due to local anesthesia during transobturator sling placement. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:247–9. 5. Atassi Z, Reich A, Rudge A, Kreienberg R, Flock F. Haemorrhage and nerve damage as complications of TVT-O procedure: case report and literature review. Arch Gynecol Obstet 2008; 277:161–4. 6. Geis K, Dietl J. Ilioinguinal nerve entrapment after a tension-free vaginal tape (TVT) procedure. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:136–8. 7. Hilton P, Mohammed KA, Ward K. Postural perineal pain associated with perforation of the lower genital tract due to insertion of a tension-free vaginal tape. BJOG 2003;110:79–82. 8. Abbas Shobeiri S, Gasse RF, Chesson RR, Echols KT. The anatomy of midurethral slings and dynamics of neurovascular injury. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:185–90.
Obturator Neuropathy After TVT Placement
OBSTETRICS & GYNECOLOGY
Obturator Neuropathy After Retropubic Tension-Free Vaginal Tape Placement Aparna Ramanathan, MD, Stefanie Bryant, MD, T. Ignacio Montoya, MD, and Clifford Y. Wai, MD BACKGROUND: We report a case of obturator neuropathy associated with retropubic midurethral sling. CASE: After retropubic tension-free vaginal tape (TVT) placement, a 36-year-old woman reported right inguinal region and thigh pain, both exacerbated with internal rotation and adduction. Neurologic examination was remarkable for two-fifths strength with right thigh adduction and an involuntary lateral drift of her right thigh with straight leg raise. Radiologic evaluation was unrevealing. With persistence of motor symptoms and pain, partial sling removal on the right was performed. Symptoms subsided postoperatively, and the patient ultimately recovered with no residual neurologic sequelae. CONCLUSION: Recognition of an atypical complication, obturator neuropathy, of retropubic TVT placement with prompt partial right sling removal on postoperative day 2 resulted in complete recovery of neurologic sequelae. (Obstet Gynecol 2015;125:62–4) DOI: 10.1097/AOG.0000000000000594
M
idurethral slings, especially the tension-free vaginal tape (TVT), have become a mainstay for the treatment of stress urinary incontinence (SUI). The procedure has demonstrated efficacy and durability1,2 with generally low rates of complications that include: hemorrhage (2–5%), bladder injury (5%), urinary retention (2–3%), and urinary tract infection (5–8%).3 From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas. Corresponding author: Clifford Y. Wai, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9032; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
62
VOL. 125, NO. 1, JANUARY 2015
Teaching Points 1. All mechanisms of neurologic injury should be considered when neuropathy occurs after retropubic placement of a midurethral sling. 2. Partial removal of tension-free vaginal tape in the immediate postoperative period can result in resolution of significant pain and motor symptoms related to the procedure with maintenance of continence.
Neuropathy is a documented complication of transobturator midurethral slings but is less so with a retropubic approach, with rates of 0.3% and 1%, respectively.3 We describe a rare case of obturator neuropathy associated with retropubic TVT.
CASE A 36-year-old healthy multiparous woman with normal body mass index was scheduled for surgery at a universitybased teaching hospital for the bothersome stress component of her mixed urinary incontinence. She had an unremarkable surgical history except for a prior bilateral tubal ligation. She had no symptoms of prolapse nor report of urinary retention. Aside from urodynamic stress incontinence the urodynamic evaluation was unremarkable, with normal capacity, normal flow rate, detrusor void, no detrusor overactivity, and a nonelevated postvoid residual. The patient underwent retropubic TVT (Gynecare TVT) placement with cystourethroscopy. The trocar on the patient’s left was placed without incident. With the right trocar, some brisk bleeding was encountered that abated with some vaginal pressure; otherwise, placement was unremarkable. The total estimated blood loss for the procedure was 100 mL. Cystourethroscopic survey after each trocar passage demonstrated no injury to the bladder or the urethra. In the postanesthesia care unit, the patient reported muscle cramping in the right inguinal region and thigh, both of which were exacerbated by internal rotation and adduction. She was unable to bear weight on the right and needed assistance to ambulate to the restroom. Although injury from trocar placement was entertained as a working diagnosis, neurologic injury from patient positioning and expanding hematoma in the retropubic space were also part of the differential diagnosis. A stat hematocrit level was 29.6 g/dL (decreased from a preoperative value of 38.4 g/dL), and the patient was hemodynamically stable. However, given the presentation and severity of the symptoms, the patient was admitted for further observation, serial hematocrit assessments (which stabilized at 27.1 g/dL), and diagnostic evaluation. On postoperative day one, the patient reported slight interval improvement in discomfort and mobility but had persistence of neurologic symptoms, with moderate pain
OBSTETRICS & GYNECOLOGY
associated with right thigh adduction but none at rest. She also denied any sensory deficits. Notable neurologic examination findings included two out of five strength with right thigh adduction and an involuntary lateral drift of her right thigh with straight leg raise—distributions highly suggestive of obturator nerve involvement. The physical therapy department was consulted for evaluation; they concurred with obturator neuropathy and initiated exercise therapy and occupational health recommendations. An abdominal and pelvic computed tomography scan was obtained and ruled out presence of a hematoma, with no other significant findings. With the elimination of compression by hematoma as a diagnosis coupled with continued weakness with thigh adduction, neuropathy from trocar placement remained as the main diagnosis. The patient was taken back to the operating room and underwent right partial sling removal on postoperative day 2. The suture of the original suburethral midline incision was cut and opened to access and isolate the sling. The sling then was transected on the right ;3 cm lateral to the midline incision of the vagina, and the remaining portion of mesh extending into the right periurethral tunnel was removed easily, along with 75 mL of clot. The incision was closed with 2-0 delayed absorbable suture. The day after partial sling removal, the patient reported moderate improvement in right thigh adduction and significantly decreased pain. Owing to the incomplete resolution of symptoms, albeit mild, the neurology department was consulted; they recommended a nerve conduction study and electromyography 2 weeks postoperatively to assess for muscle denervation. The patient continued to show improvement in both pain symptoms and strength and was able to ambulate easily with very minimal assistance from a walker. She was discharged home with a prednisone taper and outpatient physical therapy. Over the subsequent 2 weeks, the patient had further improvement in pain and strength, with complete resolution of symptoms 3 months after partial sling release. The patient was monitored in the urogynecology clinic for
a year and a half and has had no residual motor deficits nor neuropathic symptoms. A nerve conduction study using patch electrodes of the right lower extremity was normal. The patient declined the needle electromyography portion of the testing, citing complete recovery and no residual motor deficits. She has had good control of urgency incontinence symptoms with anticholinergic medication use. She denies recurrence of bothersome SUI symptoms and, on examination, has not leaked with cough stress testing.
DISCUSSION Neurologic injury is a debilitating condition and has a clinical presentation that can involve altered sensation, pain, and motor deficits. Cases of neuropathy after midurethral slings are rare, with only a few reports in the literature. One report details the transient effects of local anesthesia on the obturator nerve during placement of a transobturator sling.4 Another describes symptoms resulting from the obturator nerve encircled by a tape also placed by a transobturator route.5 Removal of the sling led to ultimate resolution of neurologic symptoms. Other reports describe ilioinguinal pain6 and perineal pain7 with a retropubic midurethral sling. Our report illustrates a rare case of obturator neuropathy occurring after retropubic midurethral sling placement. Although hemorrhage, bowel and bladder injury, and urinary tract infection all have been reported with retropubic TVT midurethral slings, obturator neuropathy is not a typical complication that has been reported. Given the trajectory of the retropubic midurethral sling trocar (as opposed to a transobturator technique), one may not reflexively entertain obturator nerve injury as high on the differential diagnosis. However, it is important to
Fig. 1. Retropubic view of right obturator internus muscle and obturator neurovascular bundle in a cadaver specimen. A. Normal trajectory of tension-free vaginal tape (TVT) trocar. B. Lateral rotation and cephalic deviation (white arrow) of TVT trocar with the tip in close proximity to obturator neurovascular bundle. Dotted line represents normal trajectory of trocar. PS, pubic symphysis; ObNVB, obturator neurovascular bundle; OBIntM, right obturator internus muscle. Ramanathan. Obturator Neuropathy After TVT Placement. Obstet Gynecol 2015.
VOL. 125, NO. 1, JANUARY 2015
Ramanathan et al
Obturator Neuropathy After TVT Placement
63
remember that all possibilities and mechanisms of injury always should be considered. An anatomical study by Abbas Shobeiri and coinvestigators provide some insight into a possible mechanism of injury.8 In their study, they determined the proximity of pertinent anatomic landmarks to the trajectory of the TVT, as well as other anatomic structures that could be involved if the trocar deviated from the normal path. We, thus, theorize that there may have been lateral and cephalic excursion of the trocar bringing the tip close to the obturator neurovascular bundle. A file photograph, previously taken in the anatomy lab of our fellowship training program, of a cadaver specimen with a retropubic midurethral sling placed illustrates a normal trajectory and a lateral and cephalic deviation of the trocar (Fig. 1). Alternatively, the trocar may have deviated lower and laterally and caught part of the obturator internus muscle, leading to possible traction on the obturator nerve or obturator internus muscle. Deviation of the trocar tip can occur from failure to retain a firm hold on the trocar handle during sling placement, with resultant axial rotation of the needle tip laterally. Needless to say, one always should be cautious of straying of the trocar and, if noted, one can either redirect it or stop, remove, and replace it if necessary. In this current case, symptom presentation was striking and persistent, and the evaluation was unrevealing for the common, less severe complications generally associated with the procedure. Elimination of these from the differential diagnosis was equally important in the diagnostic workup of this patient and, in our opinion, obligatory given the acuity and persistence of symptoms. Early recognition of the symptoms, with prompt, directed removal of part or all of the sling is a mandate in such a case. Additionally, we recommend a comprehensive and timesensitive approach to evaluation of neurologic signs and symptoms after sling placement, judicious involvement of multidisciplinary input and implementation of recommendations, and early recognition
64
Ramanathan et al
with appropriate therapeutic intervention. Although there is a role for conservative treatment, especially in cases of only mild sensory complaints, we believe that operative management is warranted in instances of significant motor deficits accompanied by moderate to severe pain, given the potential for permanent nerve damage. This report illustrates that prompt recognition of an uncommon and unpredictable neuropathy during midurethral sling placement in a teaching hospital, with expeditious intervention, can, fortunately, result in complete resolution of neurologic sequelae with maintenance of continence. All mechanisms of injury should be considered in an atypical presentation despite an unremarkable intraoperative course. REFERENCES 1. Nilsson CG, Palva K, Aarnio R, Morcos E, Falconer C. Seventeen years’ follow-up of the tension-free vaginal tape procedure for female stress urinary incontinence. Int Urogynecol J 2013;24: 1265–9. 2. Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al. Retropubic versus transobturator midurethral slings stress incontinence. N Engl J Med 2010; 362:2066–76. 3. Brubaker L, Norton PA, Albo ME, Chai TC, Dandreo KJ, Lloyd KL, et al. Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study. Am J Obstet Gynecol 2011;205:498.e1–6. 4. Park AJ, Fisch JM, Walters MD. Transient obturator neuropathy due to local anesthesia during transobturator sling placement. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:247–9. 5. Atassi Z, Reich A, Rudge A, Kreienberg R, Flock F. Haemorrhage and nerve damage as complications of TVT-O procedure: case report and literature review. Arch Gynecol Obstet 2008; 277:161–4. 6. Geis K, Dietl J. Ilioinguinal nerve entrapment after a tension-free vaginal tape (TVT) procedure. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:136–8. 7. Hilton P, Mohammed KA, Ward K. Postural perineal pain associated with perforation of the lower genital tract due to insertion of a tension-free vaginal tape. BJOG 2003;110:79–82. 8. Abbas Shobeiri S, Gasse RF, Chesson RR, Echols KT. The anatomy of midurethral slings and dynamics of neurovascular injury. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:185–90.
Obturator Neuropathy After TVT Placement
OBSTETRICS & GYNECOLOGY
