CASE REPORT
Perineal Abscess Three Years After a Transobturator Sling Rafael Mendes Moroni, MD, Pedro Sergio Magnani, MD, Maria Angela Cury Ramos Carvalho, MD, Francisco Jose Candido dos Reis, MD, PhD, Luiz Gustavo Oliveira Brito, MD, PhD, and Mauricio Mesquita Sabino-de-Freitas, MD, PhD
Objective: This study aimed to report a unique perineal abscess after placement of a transobturator sling, involving the thighs and obturator regions bilaterally without involving mesh exposure. Case Report: A 66-year-old woman treated for stress urinary incontinence with a transobturator sling developed a late bilateral obturator infection 30 months after surgery. This complication appeared 6 months after chemotherapy for breast cancer. Sling removal through vaginal and bilateral inguinal incisions was performed. The patient evolved well, without recurrence of the infection or incontinence. Discussion: This case presents a unique scenario of muscle and skin infection after sling placement without any mesh exposure or vaginal involvement. The occurrence of the infection only after chemotherapy may indicate that immunosuppression had participation on its development. Care should be taken when exposing this mesh in contaminated perineal areas. Key Words: transobturator sling, perineal abscess, stress urinary incontinence (Female Pelvic Med Reconstr Surg 2014;20: 174Y176)
T
he use of synthetic midurethral slings has changed the mainstay of treatment of female stress urinary incontinence (SUI) since the introduction of the intravaginal slingplasty in 1995.1 A polypropylene tape placed under the midurethra through a small vaginal incision replaced major surgery with similar efficacy. Complications associated to the procedure were mainly related to the blind passage of trocars through the retropubic space, which resulted in many reports of urinary, bowel, and vascular injuries. To minimize these risks, the transobturator (TOT) approach was introduced in 2001, avoiding the retropubic space.2 Infectious complications unique to this route of implantation, however, were soon described, involving the thighs and obturator spaces. We report the case of a woman with late-onset post-TOT bilateral obturator abscesses and adductor compartment myositis that presented soon after chemotherapy for breast cancer without any associated vaginal symptoms.
FIGURE 1. Transobturator sling used in the surgery.
enough to impair her daily activities. She performed urodynamics, and SUI due to urethral hypermobility was diagnosed. Surgical treatment with a midurethral sling implanted through the TOT route was performed, using a macroporous, woven, polypropylene tape (Safyre T-Plus; Promedon, Co´rdoba, Argentina). This mesh has an 18.3-cm silicone anchoring column that makes it a readjustable sling (Fig. 1). The patient was followed up for 12 months and was discharged, completely continent, without complaints. Two years after surgery, she was diagnosed with locally advanced breast cancer (3A TNM stage) and was treated with neoadjuvant chemotherapy, mastectomy, and radiotherapy, with complete remission. Six months after breast surgery, she presented to the emergency department of our hospital with bilateral pain in the inguinal
CASE REPORT A 66-year-old multiparous woman was referred to our urogynecology and reconstructive pelvic surgery division in 2009, complaining of urinary loss during straining, which was severe
From the Urogynecology, Gynecological and Pelvic Reconstructive Surgery Division, Department of Gynecology and Obstetrics, Ribeirao Preto School of Medicine, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Reprints: Luiz Gustavo Oliveira Brito, MD, PhD, Hospital das Clı´nicas da FMRP-USP, Avenida Bandeirantes, 3900, 8th floor, Ribeirao Preto, Sa˜o Paulo, Brazil. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Perineal abscess after placement of a transobturator sling without mesh exposure may appear after patient immunossupression. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0b013e318286bc4f
174
www.fpmrs.net
FIGURE 2. Incision and drainage of the thigh abscesses and antibiotic coverage provided initial relief and improvement. The sling was not initially addressed because there was no detectable mesh involvement.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 20, Number 3, May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 20, Number 3, May/June 2014
Perineal Abscess After a TOT Sling
FIGURE 3. A and B, Transperineal ultrasounds showing heterogenous images on the obturator region, suggestive of collections, involving an image composed of hyperechoic lines, which represent the silicone lateral column of the sling used. C, Transvaginal ultrasound also suggestive of a collection (white arrows) involving the sling material.
region, associated with tender, fluctuant masses in the inner thighs, 3 3 cm in size. Because she had a history of a TOT procedure, gynecologic evaluation was requested. On examination, there was no vaginal discharge and no signs of mesh exposure. The patient had no vaginal or urinary complaints. She was initially treated with doxycycline, and incision and drainage of the thigh abscesses were performed (Fig. 2). There was initial improvement, but the abscesses recurred after a few weeks, bringing the patient back to the emergency department. At that time, there was spontaneous drainage of the lesions, and tissue material was sent for culture, and it was found to have Enterococcus faecalis colonization. Transperineal and transvaginal ultrasound was performed, showing bilateral anechoic collections with debris involving the muscles of the adductor compartment bilaterally, near hyperechoic images that corresponded to the silicone anchoring columns of the sling kit used (Fig. 3). Surgical exploration was performed through a midline vaginal incision with bilateral periurethral dissection and bilateral inguinal fold incisions with adductor compartment muscles dissection, in a technique similar to the one described by Reynolds et al.3 The sling was dissected off the urethra all the way up to the obturator internus muscle, and the lateral silicone column was retrieved after adductor brevis and obturator externus * 2014 Lippincott Williams & Wilkins
FIGURE 4. Surgical exploration and removal of the sling material. The Allis clamp on the left side of picture grasps the silicone column retrieved through obturator and adductor muscles dissection. www.fpmrs.net
175
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
Moroni et al
dissection, allowing complete removal of the implanted material (Fig. 4). Pus collections were found involving the silicone arms and adductor muscles, but not the suburethral tape. There were no injuries to the urinary tract during surgery. Postoperatively, the patient was treated with 14 days of ceftriaxone plus metronidazole and was discharged home. She is being followed, showing no signs of recurrence and maintaining urinary continence.
DISCUSSION Mesh-based kits for the treatment of female SUI have gained widespread acceptance among surgeons, translating into an ever-increasing number of procedures performed. The technique was first presented as a novel minimally invasive approach to the treatment of SUI, which could be performed in little time under local anesthesia.1 It involved minimal vaginal dissection and the blind passage of 2 trocars through the retropubic space. Cystoscopy was necessary to rule out bladder injury during the blind passage because the space of Retzius was traversed. The potential complications associated to the procedure were many and involved both the insertion technique, with reports of bladder perforation, iliac vessels injury, massive hemorrhage, and bowel perforation, and the mesh itself, with vaginal exposure, urethral erosion, and vaginal infection and discharge.4 In an attempt to decrease at least the complications associated to the insertion technique, a route of mesh insertion that avoided the retropubic space was first described in France in 20012 and involved the passage of a specialized needle from the crural fold, through the obturator foramen and exiting in a paraurethral position, which was used to guide a mesh tape that seated horizontally under the midurethra. The procedure did not require the performance of cystoscopy because the space of Retzius was avoided and the risk of bladder injury was thus minimized. This new technique, however, could not address the complications that related to the mesh itself, so vaginal and infectious complications still occurred. In addition, unique events related to the new route of implantation were described, involving the thigh adductor muscles. Game et al, in 2004, described the case of a post-TOT woman who developed urethral erosion, followed by vaginal exposure of mesh, infection, and formation of an obturator-infected hematoma, with symptoms starting soon after surgery.5 Goldman,6 in 2005, described a similar case, in which the patient developed vaginal exposure, followed by obturator abscess and cellulitis in the thigh on the first postoperative day. In 2006, DeSouza et al7 reported the case of a patient who developed mesh exposure and vaginal discharge 1 week after TOT, being initially treated with antibiotics and excision of vaginal mesh but ultimately evolving with a right thigh abscess 6 months after surgery. Deffieux et al,8 in 2007, reported a patient who developed vaginal erosion after placement of 2 midurethral slings, a TOT, and a tension-free vaginal tape, and ultimately evolved with both a prepubic abscess and an obturator abscess. All these reports share the fact that the patient presented vaginal exposure of the mesh material concurrently or before the presentation of thigh involvement with cellulitis or abscess. This suggests that the route of infection is ascending and that vaginal flora gains access to skin and muscular tissues of the thigh through the exposed mesh. The case presented by us is unique in the fact that the patient developed a late bilateral obturator infectious
176
www.fpmrs.net
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Volume 20, Number 3, May/June 2014
complication without any vaginal involvement. The fact that the thigh infection appeared as an isolated complication after chemotherapy for another disease, and the significant postoperative latency, led us into thinking that the associated immunosuppression was the key for the development of this complication. The involved microorganism, E. faecalis, is part of the intestinal and vaginal flora and could have contaminated the mesh material at the time of implantation, determining an oligosymptomatic infection that became clinically important only after immunosuppression. Type of mesh is another issue that is analyzed. Most reported cases of infectious complications after TOT suburethral slings involved ObTape (Mentor Corporation, Minneapolis, Minn),9 which was the first TOT kit available in the United States and used a nonwoven, nonknitted, thermally bonded polypropylene mesh, with nonvisible pores, characteristics that limited macrophage ingrowth and favored infection, differing from today’s mostly used type I meshes. In our case, the sling kit used, Safyre, uses type I mesh, but differs from most other kits because the mesh strip is short, situated only under the urethra, and is connected laterally to 2 self-fixating and adjustable silicone columns, which are the parts of the sling that go through the obturator foramens and adductor muscles. There is no tissue ingrowth into these silicone arms. We still do not know if the different materials composing the obturator and suburethral parts of the sling had any participation on the preferential involvement of the thighs and sparing of the vaginal segment. This is the first complication of this kind that we have had noticed for this specific sling kit. REFERENCES 1. Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 1995;29(1):75Y82. 2. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11(6):1306Y1313. 3. Reynolds WS, Kit LC, Kaufman MR, et al. Obturator foramen dissection for excision of symptomatic transobturator mesh. J Urol 2012;187(5):1680Y1684. 4. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol 2008;180(5):1890Y1897. 5. Game X, Mouzin M. Obturator infected hematoma and urethral erosion following transobturator tape implantation. J Urol 2004;171:1629. 6. Goldman HB. Large thigh abscess after placement of synthetic transobturator sling. Int Urogynecol J 2006;17:295Y296. 7. DeSouza R, Shapiro A, Westney OL. Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct 2007;18(7):817Y820. 8. Deffieux X, Donnadieu AC, Mordefroid M, et al. Prepubic and thigh abscess after successive placement of two suburethral slings. Int Urogynecol J Pelvic Floor Dysfunct 2007;18(5):571Y574. 9. Yamada BS, Govier FE, Stefanovic KB, et al. High rate of vaginal erosions associated with the Mentor ObTape. J Urol 2006;176(2):651Y654.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Perineal Abscess Three Years After a Transobturator Sling Rafael Mendes Moroni, MD, Pedro Sergio Magnani, MD, Maria Angela Cury Ramos Carvalho, MD, Francisco Jose Candido dos Reis, MD, PhD, Luiz Gustavo Oliveira Brito, MD, PhD, and Mauricio Mesquita Sabino-de-Freitas, MD, PhD
Objective: This study aimed to report a unique perineal abscess after placement of a transobturator sling, involving the thighs and obturator regions bilaterally without involving mesh exposure. Case Report: A 66-year-old woman treated for stress urinary incontinence with a transobturator sling developed a late bilateral obturator infection 30 months after surgery. This complication appeared 6 months after chemotherapy for breast cancer. Sling removal through vaginal and bilateral inguinal incisions was performed. The patient evolved well, without recurrence of the infection or incontinence. Discussion: This case presents a unique scenario of muscle and skin infection after sling placement without any mesh exposure or vaginal involvement. The occurrence of the infection only after chemotherapy may indicate that immunosuppression had participation on its development. Care should be taken when exposing this mesh in contaminated perineal areas. Key Words: transobturator sling, perineal abscess, stress urinary incontinence (Female Pelvic Med Reconstr Surg 2014;20: 174Y176)
T
he use of synthetic midurethral slings has changed the mainstay of treatment of female stress urinary incontinence (SUI) since the introduction of the intravaginal slingplasty in 1995.1 A polypropylene tape placed under the midurethra through a small vaginal incision replaced major surgery with similar efficacy. Complications associated to the procedure were mainly related to the blind passage of trocars through the retropubic space, which resulted in many reports of urinary, bowel, and vascular injuries. To minimize these risks, the transobturator (TOT) approach was introduced in 2001, avoiding the retropubic space.2 Infectious complications unique to this route of implantation, however, were soon described, involving the thighs and obturator spaces. We report the case of a woman with late-onset post-TOT bilateral obturator abscesses and adductor compartment myositis that presented soon after chemotherapy for breast cancer without any associated vaginal symptoms.
FIGURE 1. Transobturator sling used in the surgery.
enough to impair her daily activities. She performed urodynamics, and SUI due to urethral hypermobility was diagnosed. Surgical treatment with a midurethral sling implanted through the TOT route was performed, using a macroporous, woven, polypropylene tape (Safyre T-Plus; Promedon, Co´rdoba, Argentina). This mesh has an 18.3-cm silicone anchoring column that makes it a readjustable sling (Fig. 1). The patient was followed up for 12 months and was discharged, completely continent, without complaints. Two years after surgery, she was diagnosed with locally advanced breast cancer (3A TNM stage) and was treated with neoadjuvant chemotherapy, mastectomy, and radiotherapy, with complete remission. Six months after breast surgery, she presented to the emergency department of our hospital with bilateral pain in the inguinal
CASE REPORT A 66-year-old multiparous woman was referred to our urogynecology and reconstructive pelvic surgery division in 2009, complaining of urinary loss during straining, which was severe
From the Urogynecology, Gynecological and Pelvic Reconstructive Surgery Division, Department of Gynecology and Obstetrics, Ribeirao Preto School of Medicine, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Reprints: Luiz Gustavo Oliveira Brito, MD, PhD, Hospital das Clı´nicas da FMRP-USP, Avenida Bandeirantes, 3900, 8th floor, Ribeirao Preto, Sa˜o Paulo, Brazil. E-mail: [email protected]. The author has declared that there are no conflicts of interest. Perineal abscess after placement of a transobturator sling without mesh exposure may appear after patient immunossupression. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0b013e318286bc4f
174
www.fpmrs.net
FIGURE 2. Incision and drainage of the thigh abscesses and antibiotic coverage provided initial relief and improvement. The sling was not initially addressed because there was no detectable mesh involvement.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 20, Number 3, May/June 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
&
Volume 20, Number 3, May/June 2014
Perineal Abscess After a TOT Sling
FIGURE 3. A and B, Transperineal ultrasounds showing heterogenous images on the obturator region, suggestive of collections, involving an image composed of hyperechoic lines, which represent the silicone lateral column of the sling used. C, Transvaginal ultrasound also suggestive of a collection (white arrows) involving the sling material.
region, associated with tender, fluctuant masses in the inner thighs, 3 3 cm in size. Because she had a history of a TOT procedure, gynecologic evaluation was requested. On examination, there was no vaginal discharge and no signs of mesh exposure. The patient had no vaginal or urinary complaints. She was initially treated with doxycycline, and incision and drainage of the thigh abscesses were performed (Fig. 2). There was initial improvement, but the abscesses recurred after a few weeks, bringing the patient back to the emergency department. At that time, there was spontaneous drainage of the lesions, and tissue material was sent for culture, and it was found to have Enterococcus faecalis colonization. Transperineal and transvaginal ultrasound was performed, showing bilateral anechoic collections with debris involving the muscles of the adductor compartment bilaterally, near hyperechoic images that corresponded to the silicone anchoring columns of the sling kit used (Fig. 3). Surgical exploration was performed through a midline vaginal incision with bilateral periurethral dissection and bilateral inguinal fold incisions with adductor compartment muscles dissection, in a technique similar to the one described by Reynolds et al.3 The sling was dissected off the urethra all the way up to the obturator internus muscle, and the lateral silicone column was retrieved after adductor brevis and obturator externus * 2014 Lippincott Williams & Wilkins
FIGURE 4. Surgical exploration and removal of the sling material. The Allis clamp on the left side of picture grasps the silicone column retrieved through obturator and adductor muscles dissection. www.fpmrs.net
175
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
Moroni et al
dissection, allowing complete removal of the implanted material (Fig. 4). Pus collections were found involving the silicone arms and adductor muscles, but not the suburethral tape. There were no injuries to the urinary tract during surgery. Postoperatively, the patient was treated with 14 days of ceftriaxone plus metronidazole and was discharged home. She is being followed, showing no signs of recurrence and maintaining urinary continence.
DISCUSSION Mesh-based kits for the treatment of female SUI have gained widespread acceptance among surgeons, translating into an ever-increasing number of procedures performed. The technique was first presented as a novel minimally invasive approach to the treatment of SUI, which could be performed in little time under local anesthesia.1 It involved minimal vaginal dissection and the blind passage of 2 trocars through the retropubic space. Cystoscopy was necessary to rule out bladder injury during the blind passage because the space of Retzius was traversed. The potential complications associated to the procedure were many and involved both the insertion technique, with reports of bladder perforation, iliac vessels injury, massive hemorrhage, and bowel perforation, and the mesh itself, with vaginal exposure, urethral erosion, and vaginal infection and discharge.4 In an attempt to decrease at least the complications associated to the insertion technique, a route of mesh insertion that avoided the retropubic space was first described in France in 20012 and involved the passage of a specialized needle from the crural fold, through the obturator foramen and exiting in a paraurethral position, which was used to guide a mesh tape that seated horizontally under the midurethra. The procedure did not require the performance of cystoscopy because the space of Retzius was avoided and the risk of bladder injury was thus minimized. This new technique, however, could not address the complications that related to the mesh itself, so vaginal and infectious complications still occurred. In addition, unique events related to the new route of implantation were described, involving the thigh adductor muscles. Game et al, in 2004, described the case of a post-TOT woman who developed urethral erosion, followed by vaginal exposure of mesh, infection, and formation of an obturator-infected hematoma, with symptoms starting soon after surgery.5 Goldman,6 in 2005, described a similar case, in which the patient developed vaginal exposure, followed by obturator abscess and cellulitis in the thigh on the first postoperative day. In 2006, DeSouza et al7 reported the case of a patient who developed mesh exposure and vaginal discharge 1 week after TOT, being initially treated with antibiotics and excision of vaginal mesh but ultimately evolving with a right thigh abscess 6 months after surgery. Deffieux et al,8 in 2007, reported a patient who developed vaginal erosion after placement of 2 midurethral slings, a TOT, and a tension-free vaginal tape, and ultimately evolved with both a prepubic abscess and an obturator abscess. All these reports share the fact that the patient presented vaginal exposure of the mesh material concurrently or before the presentation of thigh involvement with cellulitis or abscess. This suggests that the route of infection is ascending and that vaginal flora gains access to skin and muscular tissues of the thigh through the exposed mesh. The case presented by us is unique in the fact that the patient developed a late bilateral obturator infectious
176
www.fpmrs.net
&
Volume 20, Number 3, May/June 2014
complication without any vaginal involvement. The fact that the thigh infection appeared as an isolated complication after chemotherapy for another disease, and the significant postoperative latency, led us into thinking that the associated immunosuppression was the key for the development of this complication. The involved microorganism, E. faecalis, is part of the intestinal and vaginal flora and could have contaminated the mesh material at the time of implantation, determining an oligosymptomatic infection that became clinically important only after immunosuppression. Type of mesh is another issue that is analyzed. Most reported cases of infectious complications after TOT suburethral slings involved ObTape (Mentor Corporation, Minneapolis, Minn),9 which was the first TOT kit available in the United States and used a nonwoven, nonknitted, thermally bonded polypropylene mesh, with nonvisible pores, characteristics that limited macrophage ingrowth and favored infection, differing from today’s mostly used type I meshes. In our case, the sling kit used, Safyre, uses type I mesh, but differs from most other kits because the mesh strip is short, situated only under the urethra, and is connected laterally to 2 self-fixating and adjustable silicone columns, which are the parts of the sling that go through the obturator foramens and adductor muscles. There is no tissue ingrowth into these silicone arms. We still do not know if the different materials composing the obturator and suburethral parts of the sling had any participation on the preferential involvement of the thighs and sparing of the vaginal segment. This is the first complication of this kind that we have had noticed for this specific sling kit. REFERENCES 1. Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol 1995;29(1):75Y82. 2. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 2001;11(6):1306Y1313. 3. Reynolds WS, Kit LC, Kaufman MR, et al. Obturator foramen dissection for excision of symptomatic transobturator mesh. J Urol 2012;187(5):1680Y1684. 4. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol 2008;180(5):1890Y1897. 5. Game X, Mouzin M. Obturator infected hematoma and urethral erosion following transobturator tape implantation. J Urol 2004;171:1629. 6. Goldman HB. Large thigh abscess after placement of synthetic transobturator sling. Int Urogynecol J 2006;17:295Y296. 7. DeSouza R, Shapiro A, Westney OL. Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct 2007;18(7):817Y820. 8. Deffieux X, Donnadieu AC, Mordefroid M, et al. Prepubic and thigh abscess after successive placement of two suburethral slings. Int Urogynecol J Pelvic Floor Dysfunct 2007;18(5):571Y574. 9. Yamada BS, Govier FE, Stefanovic KB, et al. High rate of vaginal erosions associated with the Mentor ObTape. J Urol 2006;176(2):651Y654.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
