An early complication of Transobturator tape: Non-infective adductor internus myositis

doi:10.4236/ojog.2012.23061

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Open Journal of Obstetrics and Gynecology, 2012, 2, 289-290 OJOG

http://dx.doi.org/10.4236/ojog.2012.23061 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

An early complication of transobturator tape:

Non-infective adductor internus myositis*

Marc A. Lucky#, Paul Irwin, Saleem Bicha

Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK

Email: #[email protected]

Received 10 April 2012; revised 23 May 2012; accepted 5 June 2012

ABSTRACT

The transobturator tape (TOT) procedure is gener-

ally felt to be a safer surgical alternative to the ten-

sion-free vaginal tape procedure for women with stress

urinary incontinence. We report a case of adductor

internus myositis not associated with infection fol-

lowing the TOT procedure. To our knowledge this is

the first case of this type reported in the literature. A

43 year old lady underwent a straightforward elec-

tive TOT procedure. There were no intraoperative

complications. Immediately following the procedure

she complained of pain in her right thigh. MRI con-

firmed abnormal oedema within the antero-inferior

aspect of the right obturator internus muscle consis-

tent with myositis secondary to tape insertion. The

tape was removed the following day in theatre, fol-

lowing which her pain resolved. This case highlights a

previously unreported complication as a result of the

TOT procedure.

Keywords: Transobturator Tape; Adductor Internus

Myositis; Complication

1. INTRODUCTION

The tension-free vaginal tape procedure has been used

widely in the past for female stress incontinence. This

procedure is associated with complications such as blad-

der perforation, excessive bleeding, tape erosion, nerve

damage and haematoma formation [1]. An alternative is

the transobturator tape (TOT) procedure. It is thought to

be associated with a lower risk of complications and

lower post-operative morbidity [2]. In this minimally

invasive procedure specially designed introducers allow

the accurate placement of a synthetic tape behind the

urethra and through the obturator foramina towards the

thigh folds in line with the clitoris. The tape is positio ned

without tension , forming a sling under th e junction of the

mid and distal urethra. The trajectory of the tape is such

that it is coursed away from the obturator, femoral and

saphenous nerve s a nd vessels .

However, the TOT procedure is not without risks. As

with all synthetic materials the risk of infection, erosion

and myositis exists. The published available literature

regarding these complications is scarce. De Souza et al.

discussed a case of addu ctor brevis myositis in a 43 year

old woman with cellulitis and v aginal discharge who had

a visibly eroded mesh [3]. Leanza et al. also published a

report of a late complication of abscess and myositis af-

ter insertion of a TOT [4]. These are the only cases re-

ported in the literature of myositis of adductor muscles

associated with infection as a possible complication fol-

lowing the TOT procedure. We therefore review and de-

scribe a unique case of a symptomatic patient suggestive

of adductor internus myositis following a TOT proce-

dure, in which there was no evidence of infectio n. To our

knowledge, this is the first case reporting adductor

myositis following a TOT procedure without infection in

the literature.

2. CASE PRESENTATION

A 43 year old lady was admitted for an elective TOT

procedure. She had a 5 year history of urinary inconti-

nence which had not responded to anticholinergic medi-

cation and pelvic floor physiotherapy. The procedure was

performed without any complication; immediate post-

placement cystoscopy confirmed that there was no per-

foration of the bladder. In the recovery room she com-

plained of severe sharp shooting pains in her right thigh

upon movemen t and felt as though she had a “dead ” leg.

There was no vascular compromise, paraesthesia, swell-

ing, muscular tenderness or calf pain. She was observed

overnight and com m e nced o n tramadol.

*Conflicts of interes t: No conflicts of int erest.

Disclosures: None.

Funding: None.

#Corresponding author.

Her pain persisted overnight, now being located mainly

in the antero-medial and mid thigh level. She also had

pain on movement and weight bearing. There was no

OPEN ACCESS

M. Lucky et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 289-290

290

vascular compromise or paresthesia. Her white cell count

and inflammatory markers remained normal, and there

was no evidence of localised cellulitis. She remained

afebrile.

A MRI scan showed abnormal oedema within the an-

tero-inferior aspect of the right obturator internus muscle.

No haematoma or abscess was seen. A decision was

made to return to theatre to remove part of the tape. The

lateral end of the tape on the right side was subsequently

removed through the original incision, without complica-

tion under general anaesthetic. There was no evidence of

infection at the time of or following the procedure. The

remainder of the tape was left in place. Upon recovery,

the patient immediately reported a dramatic cessation of

pain. The following day she was mobilizing well and she

was discharged 4 days after the original TOT procedure.

Her stress urinary incontinence returned a few days later.

She has subsequently had a successful colposuspension.

3. DISCUSSION

The TOT procedure is a safe and effective treatment op-

tion for women suffering with stress incontinence, asso-

ciated with a very low risk of complications [5]. The

procedure can be done under general or local anaesthetic.

The patient is placed in exaggerated lithotomy position

with thighs in hyperflexion and slight abduction. A

Foley’s catheter is placed in the urethra. Two small inci-

sions are made in the inferior part of the obturator for a-

men at the level of the clitoris. A 2 - 3 cm incision is

made in the midline of the vagina just under the mid-

urethra, allowing the mesh tape to be placed under the

urethra in the correct position. Blunt dissection is made

in the direction of the ischiopubic rami. A curved tun-

neler is then used to place the mesh. The distal segment

of the tunneler is manipulated to pass through the obtu-

rator membrane. The mesh is then passed through the

adductor brevis, obturator externus then obturator inter-

nus, using a pronating motion. The tunnelers carrying the

mesh are brought out through the skin incision in the

groin area. The mesh is then placed under the urethra

ensuring it is tension free. Excess tape is trimmed and

incisions are sutured.

We believe that this case report is the first to highlight

a possible complication of non-infective myositis result-

ing from the TOT procedure. In this case there was no

reason to suspect surgical error. The operation was car-

ried out by an experienced urologist who had done many

of these procedures before and there were no unexpected

problems. The symptoms experienced by the patient

could possibly be explained by the course of the tape

through the various anatomical structures resulting in

inflammation or irritation of muscle tissue. This case is

useful from an educational point of view in highlighting

a potential complication of this otherwise safe procedure.

This case also demonstrates that in patients with unila-

teral symptoms, not associated with infection, it may

only be necessary to remove part of the tap e thereby still

leaving a chance that the patient’s stress incontinence

may be improved in spite of further intervention.

4. CONCLUSION

It is important that should a patient suffer with any

neurological type symptoms following a TOT procedure

that imaging in the form of CT or MRI should be done

urgently to assess further, with a low threshold for re-

moving the entire or part of the tape.

REFERENCES

[1] Karram, M.M., Segal, J.L., Vassallo, B.J. and Kleenman,

S.D. (2003) Complications and untoward effects of the

tension-free vaginal tape procedure. Obstetrics and Gy-

naecology, 101, 929-932.

doi:10.1016/S0029-7844(03)00122-4

[2] Barber, M.D., Gustilo-Ashby, A.M., Chen, C.C., Kaplan,

P., Paraiso, M.F. and Walters, M.D. (2006) Perioperative

complications and adverse events of the MONARC tran-

sobturator tape, compared with the tension-free vaginal

tape. American Journal of Obstetrics & Gynecology, 195,

1820-1825. doi:10.1016/j.ajog.2006.07.007

[3] De Souza, R., Shapiro, A. and Westney, O.L. (2007) Ad-

ductor brevis myositis following transobturator tape pro-

cedure: A case report and review of the literature. Inter-

national Urogynecology Journal and Pelvic Floor Dys-

function, 18, 817-820. doi:10.1007/s00192-006-0220-9

[4] Leanza, V., Garozzo, V., Accardi, M., Molino, A., Conco,

M. and Basile, A. (2008) A late complication of transob-

turator tape: Abscess and myositis. Minerva Ginecologica,

60, 91-94.

[5] Costa, P. and Grise, P. (2004) Surgical treatment of fe-

male stress urinary incontinence with a trans-obturator-

tape (TOT) Uratape: Short term results of a prospective

multicentric study. European Urology, 46, 102-107.

doi:10.1016/j.eururo.2004.03.005