What are the potential harmful effects of a bladder sling?

Potential Harmful Effects of Bladder Sling

Bladder slings can cause serious complications including urethral erosion, vaginal extrusion, bladder perforation, and urinary retention that may significantly impact morbidity, mortality, and quality of life. 1

Common Complications

Immediate/Perioperative Complications

• Bladder perforation: Occurs in approximately 4.5% of retropubic slings versus 0.6% of transobturator slings 1
• Bleeding: Including retropubic or vaginal hematomas 2
• Urethral injury: Can occur during placement 2
• Bowel perforation: A rare but life-threatening complication 1
• Vascular injury: Including major vessel damage during placement 1

Short-term Complications

• Urinary tract infection: Occurs in approximately 11-15% of cases 1
• Voiding dysfunction: Occurs in approximately 9-10% of cases, more common with retropubic approach 1
• Urinary retention: Can persist for more than 1 month in 3-8% of cases depending on sling type 1
• Pain:
  • Groin pain: More common with transobturator approach (6.4% vs 1.3%) 3
  • Suprapubic pain: More common with retropubic approach (2.9% vs 0.8%) 3
  • Chronic pelvic pain: Can persist long-term 2

Long-term Complications

• Mesh erosion/extrusion:

  • Vaginal extrusion: Occurs in approximately 2.1-2.4% of cases 3
  • Urethral/bladder erosion: More common with synthetic slings placed at bladder neck (5%) 1
  • Can lead to infection, pain, and dyspareunia 1

• Overactive bladder symptoms:

  • De novo urgency: Occurs in 5-25% of women after sling surgery 4
  • Worsening of pre-existing OAB symptoms 4

• Vesicovaginal fistula: A rare but serious complication requiring complex repair 2

• Bladder wall abscess: A rare complication that can develop months after the procedure 5

• Bladder stones: Almost invariably develop if exposed mesh has been present for >3 months 6

• Need for repeat surgery: Higher with transobturator approach in long-term follow-up 3

Risk Factors for Complications

• Prior radiation therapy: Increases risk of erosion (relative risk 2.97) 1
• Concurrent urethrovaginal fistula: Contraindication for synthetic sling 1
• Pre-existing urethral erosion: Contraindication for synthetic sling 1
• Urethral diverticulum: Contraindication for synthetic sling 1
• Intraoperative urethral injury: Contraindication for continuing with synthetic sling 1

Warning Signs of Unrecognized Complications

Patients should be monitored for:

• Persistent dysuria
• Recurrent urinary tract infections
• Hematuria
• Chronic pelvic pain
• Abnormal vaginal discharge
• Persistent urinary leakage
• Voiding difficulties 2, 6

Diagnostic Approach for Suspected Complications

• Cystoscopy: Essential for identifying erosion, perforation, or stones 1, 6
• Imaging: May be needed to evaluate mesh position and complications 6
• Urodynamic testing: To assess for obstruction or detrusor dysfunction 4

Management of Complications

• Mesh erosion/extrusion: May require surgical removal of exposed mesh 6
• Urinary retention: May require sling revision or division 1
• Overactive bladder symptoms: Conservative management, possible sling incision, sacral neuromodulation, or botulinum toxin 4
• Vesicovaginal fistula: Surgical repair with layered closure 2
• Recurrent stress incontinence after sling removal: May require alternative treatments such as periurethral bulking agents or pelvic floor electrical stimulation 2

Patients should be thoroughly counseled about these potential complications before undergoing bladder sling surgery, with particular attention to the risk of life-threatening complications such as bowel and vascular injuries, and the possibility of long-term issues requiring additional interventions.