Late urological manifestation of stress incontinence surgery

Abstract

The Stamey procedure was a popular procedure for female stress incontinence practiced widely in the 1980s before it was abandoned owing to high complication rates. The procedure aimed to suspend the bladder neck by placing two transvaginal Dacron buttress grafts either side of the bladder neck and suspending them with sutures passed through the retropubic space and tied suprapubically. Erosion of the graft into the bladder was a recognised complication. We report a case of an 84-year-old lady who presented with urinary symptoms forty years after an unspecified stress incontinence procedure. Imaging and cystoscopy revealed an eroded graft in her bladder wall. Further investigation revealed the graft was a Dacron buttress from a Stamey procedure. This case highlights the importance of having a working knowledge of historical techniques that may present with complications many years later and recognising the symptoms that should prompt early investigation.

Background

The subject of this case presented with urinary symptoms having undergone a procedure for stress incontinence many years before. Details of the original procedure were not available. Cystoscopy revealed what appeared to be a calcified loop of mesh like material within the bladder. After the foreign material had been excised cystoscopically using laser and laparoscopic scissors, it became evident that the item was a piece of Dacron used as a buttress during a Stamey procedure. Urological surgeons can find themselves in a position where they have to manage the complications of surgery that is now outdated. This necessitates a broad range of surgical skills and a working knowledge of historical procedures.

Case presentation

An 84-year-old woman with good performance status presented to a urology department with recurrent urinary tract infections, right lower abdominal pain, dysuria, overactive bladder symptoms and mixed urinary incontinence. She had previously undergone a surgical procedure for stress incontinence in the 1980s. Precise details of the procedure were not available but the patient had been informed that foreign material had been inserted. Forty years later, she developed right lower abdominal discomfort associated with dysuria, increased day time frequency, nocturia, urgency, urge incontinence and mild stress incontinence. Her symptoms did not improve with antibiotics. Surgical history included appendicectomy, ovarian cyst removal, cholecystectomy, hysterectomy, bilateral salpingo-oophorectomy and adhesionlysis. The patient also had a medical history of hypothyroidism, hypertension, diverticulitis, Barrett’s oesophagus, hiatus hernia, lichen planus, lipodermatosclerosis and osteoporosis.

Investigations

A CT scan performed in 2019 to investigate her symptoms detected a 2 mm partly calcified mass in her bladder neck. A patient was thereby referred to the urology department for further investigation of a suspected transitional cell carcinoma of the bladder. A flexible cystoscopy showed that the mass was in fact an erosion of a loop of foreign material into the right bladder wall at the 10 o’clock margin with surrounding stone formation. Cystoscopy was otherwise unremarkable. The patient subsequently underwent a MRI scan which showed that the foreign material was entirely intravesical and there were no extravesical portions identified.

Treatment

The patient was started on prophylactic oral antibiotics and consented for examination under anaesthesia, cystoscopy with transurethral excision of mesh as well as laparotomy and open excision if required. Vaginal examination revealed no extruded mesh. Cystoscopy revealed a part calcified foreign body at the right lateral wall close to the bladder neck (figures 1–3). The rest of the bladder was unremarkable. The distal end of the calcified material was removed using a Holmium laser at 0.8J and 10 Hz frequency. Laser effectively removed any calcifications but the identity of the foreign material was not clear. Laparoscopic scissors were then passed alongside a 22 Fr scope. The loop of mesh was cut from the bladder at one end and then was easily freed with minimal traction using biopsy forceps and withdrawn from the bladder (figure 4). The mesh was sent for histopathological examination. Relook cystoscopy revealed no remaining mesh within the bladder and no obvious perforation. Haemostasis was achieved with rollerball diathermy. A 16 Fr two way catheter was inserted and left on free drainage.

Figure 1.

Images from rigid cystoscopy.

Figure 2.

Images from rigid cystoscopy.

Figure 3.

Images from rigid cystoscopy.

Figure 4.

Excised foreign material.

The patient did not experience intraoperative or postoperative complications. She was started on a short course of oral antibiotics postoperatively and discharged the following day with a catheter in situ which was successfully removed 72 hours after the procedure.

Outcome and follow-up

Histology confirmed a 21×6×1 mm strip of man-made fibre which was white with brown staining.

The patient was followed up 4 weeks later with a repeat flexible cystoscopy which did not show any gross abnormalities. The bladder had healed well and there was no residual foreign material. Her pain and infections had resolved. She did however unfortunately report ongoing stress urinary incontinence which has been initially managed conservatively. Surgical options will be discussed if initial conservative management is not successful.

Discussion

The Stamey procedure was a popular technique used to treat female stress incontinence up until the mid 1980s.¹ The technique involves passing a single-holed ligature carrier (Stamey needle) through two small suprapubic incisions either side of the midline through the retropubic space to ipsilateral transvaginal incisions either side of the bladder neck.² A 70° cystoscope is then used to verify the position of the needle and ensure there is no perforation of the bladder which is incidentally why Stamey originally described the procedure as an ‘endoscopic suspension of the bladder neck’. A no. 2 monofilament nylon suture is then threaded through the eyelet of the Stamey needle and drawn up to the ipsilateral suprapubic incision. The Stamey needle is then passed a second time 1 cm lateral to the initial pass and passed through to the transvaginal incision and its position again checked cystoscopically. The vaginal end of the Nylon suture is threaded through a small piece of Dacron (Polyethylene terephthalate) tubing and the end then placed in the eyelet of the needle before being drawn back through the suprapubic incision. The procedure is repeated on the contralateral side and the bladder neck is elevated and suspended by pulling up on the sutures and tying them off.²

The Stamey procedure was considered a less invasive and relatively simple operation when compared alternatives including open retropubic bladder neck suspension techniques.^{3 4} Several reports have demonstrated the short-term benefits of this procedure,^{1 5} however, over time, its long-term complications became more apparent. Studies in the literature have highlighted risks associated with the procedure and the use of Dacron bolsters.^{4 6}

Clemens et al⁷ conducted a retrospective study that compared the outcomes and complications of the Stamey procedure with the Marshall-Marchetti-Krantz vesicourethropexy for stress incontinence. It showed that while both procedures yielded similar long-term continence rates, the Stamey procedure was associated with significantly higher morbidity compared with the Marshall-Marchetti-Krantz vesicourethropexy (70% vs 28%). Takahashi et al⁴ estimated the postoperative complication risk of the procedure to be 37%, among which bladder erosions were deemed a rare complication. Nonetheless, numerous patients have presented with consequences of erosion from graft migration many years after their initial operations. Jarvis⁸ reported this complication in about 1.5% of 200 patients while Richardon et al⁹ reported this in 5% of 163 patients. The onset of graft migration after the initial operation was unpredictable. Weiss and Cohen.¹⁰ reported this 4 years after the initial Stamey procedure while others reported similar cases 7 years later.¹¹ The longest was Gregorakis et al who treated a case of graft migration 19 years after the Stamey procedure.¹² While late presentations of erosions of graft material into the bladder following the Stamey procedure are recognised in the literature, this case highlights the importance of appropriate follow-up and investigation of patients with urinary symptoms many years after stress incontinence surgery.

Patient’s perspective.

‘Following a hysterectomy when I was 41 years old I had problems with bladder incontinence—when coughing, laughing and during exercise classes. In my mid forties I had bladder repair surgery and was very happy with the result. I had 80% improvement of my bladder control. I had no problems until my eighties when I had to wear liner but I put that down to age!

In the last 2 years I’ve experienced bladder infections which became ever more recurrent particularly in the last eighteen months with discomfort when emptying my bladder. This increased to the extent that my GP referred me to Urology where I was diagnosed with a bladder tumour and admitted for a camera test. In recovery the doctor was happy and amazed to discover my tumour was in fact a foreign body from the aforesaid bladder repair. I was constantly on antibiotics and in pain emptying my bladder and could finally have this foreign body removed

I was amazed to learn that surgery from my forties had lasted and worked for so long without problems and only now had some impact. After the removal of the foreign body it is wonderful to be pain free and not on constant antibiotics. My problem now is recurrent leaking which I will be seeing the doctors to help me with.’

Learning points.

• Complications of surgery involving mesh and foreign material can present many years after the initial procedure.

• In patients who have undergone surgeries such as the Stamey procedure, ongoing vigilance is required when assessing a patient with symptoms such as pain, haematuria or recurrent urinary tract infections.

• Cross-sectional imaging and cystoscopy can help identify complications relating to foreign material within the pelvis but the nature of the foreign material and the extent of the pathology may only become apparent at surgery.

• A working knowledge of historic procedures was required to establish the diagnosis in this case.

• While this patient only required transurethral excision of the foreign material, the operating surgeon needs to be flexible and have a broad range of skills to excise foreign material especially if details of the initial surgery are not available.