Outpatient management of an infected retropubic sling—a case report

Introduction

Stress urinary incontinence (SUI) affects 30–80% of women (1). Synthetic midurethral slings have been the preferred surgical technique since 1996, given its short operative time, and high success rate. The main complications are bladder perforation (2.7–3.9%), reoperation rate due to voiding dysfunction (1.6–2.4%), pelvic hematoma (0.7–1.9%), urinary retention (1.6%), vaginal tape erosion (1.5%) and infection (0.7%) (1). As the infection rates are low, there is a lack of data available on surgical site infections related to retropubic slings and their management. Prior case reports of mesh infection suggest removal of mesh material in the setting of infection (2-4). However, mesh removal requires extensive dissection and surgeon expertise. Complications from mesh removal include pain, injury to adjacent organs, bleeding, nerve injury and recurrent SUI (5). The absence of extensive data on conservative management for infected slings creates a gap in current clinical knowledge and practice.

The objective of this case report is to present the first known instance of successful conservative treatment for bilateral infected midurethral sling tracts, using oral antibiotics and hydrogen peroxide irrigation. By highlighting this novel approach, we aim to provide an alternative treatment strategy and contribute to the existing literature on the management of surgical site infections following retropubic sling placement. We present this article in accordance with the CARE reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-41/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 55-year-old para 5, with well-controlled diabetes mellitus, underwent an uncomplicated robotic assisted supracervical hysterectomy, bilateral salpingectomy, sacrocolpopexy, retropubic mid urethral sling, and cystoscopy for stage III uterovaginal prolapse and urodynamic stress urinary incontinence. The patient received 2 g of intravenous cefazolin and 500 mg metronidazole prior to skin incision, and her abdomen and vagina were prepped with chlorhexidine 4% per hospital protocol. Estimated blood loss was 100 mL, and the total operative time was 2 hours and 58 minutes. Her robotic incisions were closed with interrupted Monocryl suture, as well as surgical glue. The suprapubic trocar exit sites were closed with surgical glue alone. The patient had an uneventful postoperative course and was discharged home on postoperative day 1 with a 14 F Foley catheter after failing her voiding trial. She passed her trial of void on postoperative day 4 in the office and had no complaints at that time.

Eleven days after surgery, the patient reported increasing pressure and discomfort of the lower abdomen for 2 days despite medication management and malodorous urine. Given her symptoms and temporal proximity to her surgery, the patient was empirically prescribed ciprofloxacin 500 mg twice daily and metronidazole 500 mg three times daily for coverage of uropathogens and anaerobes.

The following day on postoperative day 12, she reported a fever of 101.9 F and imaging was ordered. Computed tomography (CT) abdomen and pelvis with contrast revealed evidence of two small abscesses within the inferior pelvis (Figure 1). The larger measuring 2.0 cm × 3.4 cm × 2.3 cm within the anterior inferior left pelvis (Figure 2). This ring enhancing tract extended from the left aspect of the urethra to the skin surface, running along the left posterior wall of the bladder (Figure 3). The smaller abscess was a 1.1 cm × 0.8 cm rim enhancing fluid collection involving the right posterior wall of the lower vagina near the introitus.

Figure 1 Two small abscesses within the inferior pelvis; larger measuring 2.0 cm × 3.4 cm × 2.3 cm.

Figure 2 The inferior aspect of the infected sinus tract (as arrow indicated).

Figure 3 A tortuous rim enhancing tract having a diameter of 8 mm and a craniocaudal dimension of approximately 4 cm extending in craniocaudal direction along the left aspect of the urethra (as arrow indicated).

The patient was recommended to be evaluated in the emergency department. However, as her symptoms improved, she was seen and examined in the office the following day, on postoperative day 13. At that time, she reported overall improvement in her abdominal discomfort, soreness, and resolution of her fever. On the physical exam, her abdominal incisions were clean, dry and intact. The retropubic sling exit sites were appropriately tender with no signs of erythema, edema, and/or fluid drainage. On vaginal exam, the sub-urethral sling sutures were present, but the surrounding tissue was erythematous and white purulent discharge was able to be expressed from the incision. No mesh exposure was noted. Given physical exam findings and CT scan findings, mesh infection was suspected. As the patient had already been on antibiotics, vaginal and urine cultures were not obtained.

Given the absence of mesh exposure, the decision was made to pursue conservative management. She was encouraged to maintain good glycemic control, to initiate vaginal estrogen cream three nights per week, complete her 14-day antibiotic course, and to perform vaginal irrigation to the sling site three-times daily with a dilute hydrogen peroxide mixture (50/50 hydrogen peroxide/water) with a peri-bottle.

The patient was seen on postoperative day 24 and decreased incisional drainage was noted. The surrounding tissue was non-erythematous and non-tender. She denied continued fevers and/or lower abdominal pain. The patient continued to recover well, and at her 2-month postoperative visit, all signs of infection resolved, and her sling incision site was completely closed without mesh exposure. At the 21-month follow-up, she remained asymptomatic, with continued effective management of her stress urinary incontinence.

Discussion

This case highlights the ability to pursue conservative management of an infected sling without the need for mesh removal in the outpatient setting. Our patient presented with typical symptoms of an infection, including fever, pain, and purulent discharge at the surgical site. Imaging confirmed the diagnosis of pelvic abscesses, but treatment with oral antibiotics and hydrogen peroxide washes resulted in full recovery, without requiring surgical intervention.

The strength of this report is its novel, conservative treatment approach for managing infected midurethral slings. Given that mesh removal is the standard treatment in similar cases, this report provides valuable insights into alternative, non-invasive management strategies that may offer comparable outcomes. However, this case report is based on a single patient, limiting its generalizability. Further studies with larger sample sizes, different risk factors and longer follow-up are needed to confirm these findings and assess potential risks.

Implementation of pre-operative antibiotics have reduced the incidence of surgical site infections but has yet to eliminate the occurrence of them (6). Gynecologic and urogynecologic procedures pose a unique risk in that the pathogenic microbes from the skin, as well as the vagina, can migrate into the operative site, leading to the formation of a pelvic abscess or pelvic cellulitis (6). Treatment of pelvic abscesses in the setting of mesh is more complicated. Current literature describes management of mesh infections as removal of the mesh material, as well as intravenous antibiotics (2-4). Mesh removal requires extensive dissection and surgeon experience. Mesh removal may have complications such as pain, injury to adjacent organs, bleeding, nerve injury and recurrent SUI (5). This case diverges from those recommendations by avoiding mesh removal and relying on oral antibiotics and hydrogen peroxide irrigation. The success of conservative management in this case may be attributed to early recognition and timely treatment of the infection, which likely prevented the need for more invasive procedures. Another factor to consider is the exteriorization of one of the abscesses into the vaginal canal. The drainage of the abscess potentially reduced bacterial load and promoted wound healing.

Hydrogen peroxide has been used in wound cleaning but recently, it has also been shown to promote wound healing and new tissue formation (7). Additionally, our patient’s well-controlled diabetes may have reduced the severity of the infection, contributing to the success of the conservative approach.

This case suggests that conservative management may be a viable option for certain patients with mesh infections, especially when mesh exposure is absent with localized infections in the early stages. Future research is needed to explore the effectiveness and safety of this approach in a larger cohort, as well as to develop standardized treatment protocols for conservatively managing mesh infections.

Conclusions

In conclusion, healthcare providers should be vigilant in recognizing signs and symptoms of infection and take appropriate measures to prevent and treat infections promptly. Prompt recognition allows conservative management to be a viable treatment option to avoid midurethral sling mesh removal.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-41/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-41/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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