Complications from Mesh Sling for Stress Incontinence: How do we handle them?
You’ve made it through surgery. You thought it was going to be straightforward. After all, it’s just a twenty-minute outpatient procedure. Your surgeon said you would only be off work for a couple of days. So, what went wrong and how is your doctor going to fix it?
In my last blog, I talked about the fact that I believe wholeheartedly in the benefits of a transvaginal mesh sling to treat stress incontinence. But, at the same time, I acknowledge that complications can occur. I know this because, in the rare instances when they do occur, I am the one that needs to resolve the issues and get the patient the results from surgery she expected.
So, what are the complications and how can we fix them? In this blog, I am going to tease apart what can go wrong and how we make things right. In doing so, I am going to divide the issues into those related to surgery in general and those specifically related to transvaginal mesh slings.
General Surgical Risks
With many surgeries, there is a risk of bleeding and infection.
Bleeding complications rarely occur with the sling and when there is bleeding, the majority of the time it is self-limited and stops on its own. In very rare cases, a return to the operating room to stop the bleeding might be necessary. However, when I say rare, I mean rare–I have never personally had to take a patient back for bleeding from a sling in the 12 years I have been doing slings.
Infection is usually treated with antibiotics and again is rare. In the case of an infected sling, the sling often must come out. The good news is that when a sling is infected, removing it is exceedingly easy because the infected tissue surrounding the sling does not grow into the sling. Urinary tract infections are by far the most common infection following a sling, and are easily treated with antibiotics.
Risks Specifically Related to the Transvaginal Mesh Sling
Although injury to the bladder can occur in up to 10% of cases, usually it is not clinically significant. The surgeon will know this has happened at the time of surgery when they look inside the bladder with a camera. The bladder has multiple layers, so when the sling is pulled out, the bladder layers slide over themselves effectively closing the hole. The sling can then be replaced, and a camera again is used to check and see if it is in the correct place (and not in the bladder). Although this doesn’t sound so good, most patients would be completely unaware that it happened if their surgeon did not share this information with them.
As the sling is placed directly beneath the urethra to prevent leakage, in some cases, patients have trouble voiding after surgery. About 20% of patients have trouble voiding immediately after surgery due to swelling or discomfort, but this usually resolves in a couple of days. Less than 1% of patients will need to return to the OR for persistent trouble voiding or other voiding issues (like recurrent bladder infections or overactive bladder). When a return to the OR is needed, it is usually a minor procedure to cut or loosen the sling.
Mesh exposure is another possible complication. I quote my patients a 1-2% chance of the incision in the vaginal skin opening over the sling exposing part of the mesh. Sometimes the patients don’t notice this but I find it on exam, or their partner might notice a scratching sensation during intercourse. Mesh exposure can be resolved with estrogen cream and excision in the office or sometimes the operating room.
One of the most dreaded potential complications from the mesh sling is pain. The last thing that a surgeon wants to have happen when fixing a quality of life problem like stress incontinence is to create another quality of life problem, like causing pain. In the instances where I have had patients develop pain after a sling, it was usually due to tension on the sling pulling in a way that was very painful to the patient with or without sex, with or without physical activity. I have found in those circumstances that simply cutting the sling at the location where it is creating the tension is the only treatment needed to relieve the discomfort. Removing the sling in its entirety is rarely if ever needed.
I have outlined the most common complications from slings that I see in my practice. These occur less than 5% of the time. I tell my patients I feel very confident I can address any complications that arise. It is important to discuss these complications and how they can be fixed with your surgeon before your transvaginal mesh sling.