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CASE REPORT
Adv Biomed Res 2021,  10:30

Labial cellulitis and suprapubic urine leakage after midurethral sling: A rare presentation of unrecognized bladder neck perforation


1 Department of Urology, Isfahan Kidney Transplantation Research Center, AL-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
2 Isfahan Kidney Transplantation Research Center, AL-Zahra Institute Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Operating Room, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission03-Dec-2020
Date of Acceptance23-Feb-2021
Date of Web Publication14-Oct-2021

Correspondence Address:
Dr. Narjes Saberi
Department of Urology, Isfahan Kidney Transplantation Research Center, AL-Zahra Research Institute, Isfahan University of Medical Sciences, Kargar Street, 1st Shahid Mahmoodreza Mahdavi Street, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abr.abr_288_20

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  Abstract 


Retropubic midurethral sling (MUS) is safe and effective surgery used for the treatment of stress urinary incontinence in women. Bladder neck perforation is a rare intraoperative complication. If this complication missed in intraoperative cystoscopy may have serious morbidity. A 52-year-old woman underwent a retropubic MUS. She presented with early and unusual symptoms such as suprapubic and labial cellulitis and urine leakage through the suprapubic incision 1 week after surgery which was due to a missed bladder neck perforation during surgery. In cystoscopy after MUS revealed mesh traversing the bladder neck and it was removed. The missed bladder perforation may have early and unusual symptoms and cystoscopy must be done more carefully and obsessively in patients with risk factors.

Keywords: Cellulitis, mid-urethral sling, urinary incontinence


How to cite this article:
Saberi N, Zargham M, Hayrabedian A. Labial cellulitis and suprapubic urine leakage after midurethral sling: A rare presentation of unrecognized bladder neck perforation. Adv Biomed Res 2021;10:30

How to cite this URL:
Saberi N, Zargham M, Hayrabedian A. Labial cellulitis and suprapubic urine leakage after midurethral sling: A rare presentation of unrecognized bladder neck perforation. Adv Biomed Res [serial online] 2021 [cited 2021 Oct 20];10:30. Available from: https://www.advbiores.net/text.asp?2021/10/1/30/327818




  Introduction Top


Stress urinary incontinence is a complaint that affects 27%–42% of Iranian women.[1] Retropubic tapes have been used for several years.[2],[3] Bladder perforation has been reported as a complication, and it is related to the blind passage of trocar.[2],[4] The rate of bladder perforation is 2%–9%.[5],[6] Undiagnosed bladder perforation has delayed and typical symptom.[4] This is the first case report of suprapubic and labial cellulitis and suprapubic urine leakage resulting from an unrecognized bladder perforation. In this case, bladder neck perforation with trocar passage led to urinary leakage, pelvic urinoma, and accumulation of urine under the suprapubic skin area, which eventually led to labial cellulitis and suprapubic urine leakage.


  Case Report Top


A 52-year-old woman presented to our institution with the complaint of left labia major, suprapubic swelling, and pain. She had a history of anti-incontinence surgery 1 week ago (retropubic midurethral sling [MUS]). In intraoperative cystoscopy, bladder perforation was not detected. Two days after catheter removal and discharge, suprapubic and left labial redness, pain, and swelling began and progressed “[Figure 1].”
Figure 1: Labial cellulitis

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On day of admission, she was afebrile, and her vital signs were stable. In physical examination, suprapubic and left labia major swelling and redness were seen. Vaginal hematoma and mesh erosion were not seen. The patient was admitted to the ward with primary diagnoses of severe reaction to the mesh and infection. Antibiotic therapy and abdominopelvic ultrasonography were done. Ultrasound was normal. The day after, fluid leakage through the left suprapubic incision started, and then, pain and swelling subsided “[Figure 2].”
Figure 2: Urine leakage through the suprapubic incision

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The fluid was not purulent or smelly. In cystoscopy revealed mesh traversing, the bladder neck on the patient's left side between the 5- and 7-o'clock positions. The vaginal wall incision was opened, and the mesh was recognized. Traction was applied, and the whole sling was removed. A 20F Foley catheter was left for drainage. Urine leakage stopped, and the patient was discharged the next day. The catheter was removed 10 days later.


  Discussion Top


We present a case who underwent a retropubic MUS and for whom we diagnosed as having a missed bladder neck perforation with early and unusual symptoms (suprapubic and labia major cellulitis and urine leakage through the suprapubic incision). At a diagnostic cystoscopy, the misplaced sling material was identified. The missed bladder perforation and subsequent mesh left within the bladder have typical symptoms (lower abdominal pain, recurrent UTI, urgency, frequency, dysuria, and urinary incontinence).[4] The average duration between the diagnosis and treatment is 7–36 months.[7],[8] Most of the patients develop calcification and a stone.[9] We report the first case of missed bladder neck perforation which appeared with early and unusual symptoms in the 1st week after surgery. The diagnosis was made by cystoscopy, and the treatment was done with the complete removal of the synthetic material. Predisposing factors for bladder perforation are surgeons' lack of experience, cystocele, advanced age, smoking, diabetes mellitus, low body mass index, previous vaginal, or pelvic surgery.[10],[11] Our case has diabetes mellitus and a previous history of vaginal repair. Cystoscopy must be done more carefully and obsessively for cases with predisposing factors. It is not always possible to recognize the misplaced mesh if it is very closely related to the bladder neck.[7] The use of a 70° lens is a very important point in the careful examination of the bladder neck and avoidance of misdiagnosis.[7],[8] In our case, bladder perforation was very close to the bladder neck.


  Conclusion Top


Although retropubic MUS surgery is a safe and effective procedure, it can have serious complications. Misplacement of the mesh material through the bladder neck is a rare complication. Suprapubic and labial cellulitis and suprapubic urine leakage can be one of the early manifestations. The cystoscopic evaluation must be performed carefully and obsessively for cases with predisposing risk factors.

Statement of ethics

The subject has obtained the patient's informed written consent to publish her photo and details.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mostafaei H, Sadeghi-Bazargani H, Hajebrahimi S, Salehi-Pourmehr H, Ghojazadeh M, Onur R, et al. Prevalence of female urinary incontinence in the developing world: A systematic review and meta-analysis – A Report from the Developing World Committee of the International Continence Society and Iranian Research Center for Evidence Based Medicine. Neurourol Urodyn 2020;39:1063-86.  Back to cited text no. 1
    
2.
Kershaw V, Nicholson R, Ballard P, Khunda A, Puthuraya S, Gouk E. Outcome of surgical management for midurethral sling complications: A multicentre retrospective cohort study. Int Urogynecol J 2020;31:329-36.  Back to cited text no. 2
    
3.
Bach F, Toozs-Hobson P. What can we learn from large data sets? An analysis of 19,000 retropubic tapes. Int Urogynecol J 2017;28:629-36.  Back to cited text no. 3
    
4.
Keltie K, Elneil S, Monga A, Patrick H, Powell J, Campbell B, et al. Re: Complications following Vaginal Mesh Procedures for Stress Urinary Incontinence: An 8 Year Study of 92, 246 Women. Scientific Reports 2017;7:1-9.  Back to cited text no. 4
    
5.
Zargham M, Saberi N, Khorrami MH, Mohamadi M, Nourimahdavi K, Izadpanahi MH. stress urinary incontinence and pelvic organ prolapse correction by single incision and using monoprosthesis: three-year follow-up. Adv Biomed Res 2018;7.  Back to cited text no. 5
    
6.
Novara G, Galfano A, Boscolo-Berto R, Secco S, Cavalleri S, Ficarra V, et al. Complication rates of tension-free midurethral slings in the treatment of female stress urinary incontinence: A systematic review and meta-analysis of randomized controlled trials comparing tension-free midurethral tapes to other surgical procedures and different devices. Eur Urol 2008;53:288-308.  Back to cited text no. 6
    
7.
Osborn DJ, Dmochowski RR, Harris CJ, Danford JJ, Kaufman MR, Mock S, et al. Analysis of patient and technical factors associated with midurethral sling mesh exposure and perforation. Int J Urol 2014;21:1167-70.  Back to cited text no. 7
    
8.
Ozdemir A, Cakır S, Sözen H, Namazov A, Akdemir Y, Karateke A. Development of bladder stone after tension free vaginal tape procedure: A case report. J Turk Ger Gynecol Assoc 2011;12:256-8.  Back to cited text no. 8
    
9.
Stav K, Dwyer PL, Rosamilia A, Schierlitz L, Lim YN, Lee J. Risk factors for trocar injury to the bladder during mid urethral sling procedures. J Urol 2009;182:174-9.  Back to cited text no. 9
    
10.
Kuhlmann PK, Dallas K, Masterson J, Patel DN, Chen A, Castaneda P, et al. Risk factors for intraoperative bladder perforation at the time of midurethral sling placement. Urology 2021;148:100-5.  Back to cited text no. 10
    
11.
Ghazi MJ, Almayali JA, Mosawi MN, Athari MH. Efficacy and perioperative morbidity of suprapubic midurethral sling surgery for females with stress urinary incontinence. Eur J Mol Clin Med 2020;7:109-16.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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