Urethral synthetic mesh erosion with formation of a large bladder and urethral stone: A case report

Abstract

Synthetic urethral support mesh has been used for many years for the treatment of urinary stress incontinence. Late complications such as pain, mesh erosion, and recurrent urinary tract infection have been well described.

A 57-year-old patient presented with a primary complaint of worsening lower urinary tract obstruction. She had undergone placement of a pubovaginal tension-free vaginal tape for the treatment of urinary stress incontinence 13 years earlier. A workup revealed a large stone arising from a section of mesh that had eroded into the proximal urethra. The stone extended from the erosion site into the bladder, creating a high-grade obstruction at the bladder neck. It is quite uncommon to see such a large stone in this setting. The long interval between the original surgery and the subsequent presentation of this complication is also unusual.

A high index of suspicion is needed to evaluate late urologic complications related to implanted synthetic mesh.

Highlights

• •Synthetic mesh has long been used for the treatment of urinary stress incontinence.
• •Late complications related to erosion of synthetic mesh may occur.
• •Late complications may include stone formation.
• •A high index of suspicion is needed to evaluate late urologic complications.

1. Introduction

Placement of synthetic sub-urethral mesh has been widely used for the treatment of urinary stress incontinence for more than 2 decades. Such procedures are relatively easy to perform, most often in the out-patient setting, and are generally efficacious. However, both early and late complications have been well described [1]. Erosion into adjacent structures, such as the urethra and bladder, has been reported in up to 0.8% of cases and can cause significant morbidity, including recurrent urinary tract infections and stone formation [2]. While even the presence of eroded bare mesh in contact with urine can lead to recurrent urinary infections, the development of a stone may add complexity to management and may present many years after the initial surgery.

2. Case Presentation

The patient was a 57-year-old woman who had undergone placement of a pubovaginal, tension-free vaginal tape, for the treatment of urinary stress-type incontinence 13 years prior. She presented with a complaint of a several-year history of gradually worsening pelvic discomfort, intermittent hematuria, interrupted urinary flow and symptoms of urgency and frequency. Documented urinary tract infection had been periodically present, although the symptoms persisted even in the absence of infection. Multiple courses of antibiotics over this period had provided only partial relief. Additionally, she was treated with anticholinergic medications, again without significant benefit. Her past medical history was otherwise unremarkable.

An abdominal/pelvic computed tomography scan demonstrated a stone measuring 3.9 × 3.3 × 3.3 cm within the dependent portion of the bladder, extending through the bladder neck into the urethra (see Fig. 1 and Fig. 2). The most distal aspect of the stone was adherent to an eroded area of the mesh sling in the proximal urethra. There was no evidence of hydronephrosis.

Fig. 1.

Preoperative abdominal/pelvic computed tomography scan demonstrating a large stone within the lumen of the bladder and extending into the proximal urethra, where it is anchored to the eroded mesh.

Fig. 2.

Composite cystoscopy view with anatomic reference demonstrating location and extent of the stone relative to the original synthetic pubovaginal mid-urethral tension-free vaginal tape.

The patient was taken to the operating room. Due to very obstructed visibility, a cystoscopic approach was not possible. An open cystolithotomy to remove the bulk of the calculus was then performed, removing the majority of the stone. However, the portion of the stone within the right proximal urethral wall adherent to remnant mesh could not be removed via the trans-vesical approach. A trans-vaginal open urethral exploration via a ventral urethrotomy was required to remove all of the stone and remnant mesh under the same anesthetic, followed by primary urethral reconstruction, including a Martius labial fat graft to bolster the closure.

Following this, she developed urinary incontinence, which transiently improved with solifenacin. Several months later, she was found to have a very short, distal urethral stricture. This was dilated without difficulty, and an additional 2 mm remnant of exposed mesh was removed with a cystoscopic grasper.

At the time of writing, the patient continues to have episodes of stress-based incontinence, which will require future treatment, likely in the form of an autologous fascial sling, depending on the results of urodynamic follow-up studies.

3. Discussion

Synthetic mesh slings and products are widely used throughout the world for the correction of pelvic prolapse and urinary stress incontinence. Millions of women have benefitted from the ease and rapidity of placement, rapid postoperative recovery and generally high efficacy.

However, since the first description in 2001, erosion of synthetic mesh used for both pelvic organ prolapse repair and for the correction of urinary stress incontinence has been well reported and studied [1,2]. A review of the subject in 2020 identified the urethra as the site of mesh erosion in 32% of cases [3]. The most common complications include pain, infection, and urinary voiding complaints, some presenting years after the original implantation [1,2,3].

Recognizing the growing awareness of complications, several countries have banned the use of transvaginal mesh devices for the treatment of pelvic organ prolapse, such as Australia and New Zealand in 2017, and the United Kingdom and Ireland in 2018.

Similarly, the United States Food and Drug Administration in 2019 ordered all manufacturers of trans-vaginal mesh for the repair of pelvic organ prolapse to withdraw their products from the market [4]. Importantly, this order did not include products designed for the correction of urinary stress incontinence, which continue to be widely marketed and used.

Treatment of symptomatic urethral mesh erosion can be particularly challenging [5,6]. Management factors include defining the extent and specific location within the urethra or other structures (e.g. vagina, bladder), the presence or absence of associated complications such as stone, and the degree of functional impairment of the bladder neck and mid-urethral sphincter.

A high index of suspicion is occasionally needed to diagnose very late urologic complications related to implanted synthetic mesh as such issues may become evident even years after the initial implant surgery.

Treatment considerations should include clearance of any associated soft tissue or urinary infection, removal of the eroded mesh and any associated stone, and potential reconstruction of any anatomic abnormalities that may affect urinary or sexual function.

Contributors

Corinne L. Puzio was involved in patient care and contributed to the writing and editing of the manuscript.

Robert A. Edelstein was involved in patient care, was responsible for the conception of the case report, and drafted the manuscript.

Both authors approved the final submitted manuscript.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Patient consent

The patient consented to the publication of this report and the accompanying images.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Conflict of interest statement

The authors, Robert Alex Edelstein and Corinne Leigh Puzio, declare that they have no conflict of interest regarding the publication of this case report.