ABSTRACT

Following a TVT midurethral sling 4 years earlier, (initially deemed 85% successful), a 53 year woman presented with gradual deterioration of her incontinence. By mid 2009, the patient was leaking 800-1000 ml/24 hours. There was no urine leak at rest or at night, but she leaked on the slightest effort during the day. On ultrasound examination, the whole posterior urethral wall was opened out during straining, with observed urine loss. The maximal urethral closure pressure was 60cm H2O, with no urodynamically detected detrusor instability. At operation, the urethra was paper thin, 1,5 cm wide, fragile and attached to a wide loose TVT tape partly embedded in the urethral wall. Two small holes were made during tape removal and repaired. A “bridge/flap” of full thickness vaginal mucosa (3x1cm) was brought up to protect the thin urethral wall. A TFS (Tissue Fixation System) adjustable midurethral sling was then inserted over the vaginal flap, then covered by approximation of the lateral vaginal edges to form a double layer. The patient was entirely cured at 12 months review, with no vaginal retention cysts evident. Though midurethral tapes generally enhance the urethral closure mechanisms, a loosely applied tape may fibrose in such a way as to “hold open” the urethra and prevent closure.