Alfonso Rossetti, Ornella Sizzi, and Giuseppe Florio M.D.
Nuova Villa Claudia Hospital, Rome, Italy

A 52 year old female patient was referred to our office for vaginal vault prolapse and cystocele. The patient was already operated on vaginal hysterectomy and TVT three years before in another institution. Hysterectomy was performed for multiple myomas and the TVT for correction of a mild genuine urinary stress incontinence. The postoperative course was uneventful and the patient was discharged after three days. Since the operation the patient developed more and more serious bowel dysfunctions with severe constipation and repeated episodes of bowel sub-obstruction. A laparoscopy with a high McCall colposuspension with paravaginal repair was planned. After insertion of the laparoscope, the distal part of the vaginal tape was observed emerging from the anterior abdominal wall, next to the bladder and protruding into the abdominal cavity.

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The tape passed through the meso of a loop of the small intestine, binding the ileum to the anterior abdominal wall. The meso perforation was few millimetres from the bowel serosa. After introduction of three accessory trocars, the tape was cut in its intraperitoneal portion next to its upper exit from the abdominal wall and next to the bowel serosa. The ileum was successfully mobilized and the lower part of the tape was observed, emerging from the meso and going towards the abdominal wall to exit next to the bladder dome. The tape was cut in a similar fashion, after lysis of adhesions between the small bowel and the abdominal wall.

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The laparoscopic colposuspension was carried out as planned and the patient recovered quickly.

 TVT was a treatment for stress incontinence with an objective cure rate of 84-100%, with few complications. TVT was considered a safe procedure usually performed under regional or local anaesthesia with sedation. According to randomized clinical trial, surgery with TVT is associated with more operative complications than colposuspension, largely injury to the bladder (9%) and vagina (3%). This does not appears to carry any long-term risk provided that it is recognized at the time of operation when it can be managed conservatively with postoperative bladder drainage. More concern is for vascular injuries ( mostly external iliac or obturator vessels). Vascular injury rate varies among 0.5% to 0.01%. Obturator nerve injuries is variable ( 0.2 to 1.8) with a mean rate of 2 out of 1000 procedures. Bowel perforations were already reported in the three case reports, but the real incidence is unknown. This is equivalent to one of these serious complications reported for every 5000 procedures. It can be concluded that TVT can be considered a safe procedure with an acceptable complication rate, but is has to be borne in mind that serious complications requiring immediate laparotomy do occur. Patients who have had previous combined pelvic intra- and extra-peritoneal surgery should be operated on by experienced surgeons and be observed for hours. As the retropubic space is preserved intact, the placement of a transobturator tape could be preferable in such cases.

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As shown in this video the possibility of a damage of the major vessels and of the obturator nerve or of the bowel can be considered extremely low.



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