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Thigh Dissection for Thigh Pain After Transobturator Sling Placement
abstract
This abstract is available on the publisher's site.
Access this abstract nowPURPOSE
Transobturator slings have higher rates of de novo neurologic symptoms than retropubic slings, most commonly related to the thigh. Cases refractory to conservative management may require removal of the thigh portion of the sling. In this series we prospectively examine the effect of thigh dissection with mesh removal on refractory thigh pain.
MATERIALS AND METHODS
All thigh dissections for refractory neurologic symptoms after transobturator sling placement were followed prospectively from October 2012 to October 2015. Patients were assessed preoperatively, with a pain score using a visual analog scale, and postoperatively with a global response assessment.
RESULTS
A total of 12 thigh dissections were performed from October 2012 to October 2015 in 8 patients. Mean (±SD) time from original mesh placement to presentation was 2.7 (±1.5) years. Average preoperative pain score was 7.9 (±1.7) out of 10, with pain in the thigh in all patients. Seven cases involved unilateral thigh dissection and 1 had concomitant bilateral thigh dissection. Five patients underwent concurrent transvaginal excision. On postoperative evaluation the average global response rating was 1.6, with 1 defined as very much better and 2 defined as much better. Of the 8 patients 3 went on to have the contralateral side done with an average global response rating of 1.3 (±0.6). One patient underwent further treatment for stress urinary incontinence with placement of a retropubic mid urethral sling.
CONCLUSIONS
Our prospective series supports the use of thigh dissection in patients with refractory neurologic symptoms after transobturator sling placement. The procedure can be performed safely with positive outcomes for the patient.
Additional Info
Disclosure statements are available on the authors' profiles:
Prospective Evaluation of the Effect of Thigh Dissection for Removal of Transobturator Mid Urethral Slings on Refractory Thigh Pain
J Urol 2016 Oct 01;196(4)1207-1212, AB King, C Tenggardjaja, HB GoldmanFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The authors review their extended evaluations of thigh pain after obturator and groin dissection for removal of transobturator tapes due to persistent and refractory leg and thigh pain after placement of midurethral sling.
They report reasonably salubrious results with minimal morbidity. They call this a prospective evaluation, although this really is a retrospective case series and should be viewed as such.
Vanderbilt University has had substantial experience with this and was actually the first group to report extended dissection for the condition of pain after midurethral sling implantation using the obturator route.
A few words of warning for those considering doing this procedure. Initial assumptions were that if the sling was removed for tension, pain would resolve. Our initial approach has been to incise and remove vaginal components of the sling. However, we noted persistence in many of our patients of their pain and therefore added unilateral groin dissection where appropriate. This groin dissection follows the ipsilateral groin crease and goes to the level of tendon insertion into the pelvis. Additionally, there is the possibility that the obturator membrane must be traversed to identify and remove the sling materials. The sling itself is often found immediately either just opposed to the tendon or immediately through the tendon, indicating at least the potential of technical error during implantation.
We have also found in our series, which is now larger than the reported one, sling material quite distally in the ductal muscle, indicating again technical error in placement. We have also found sling material literally in immediate co-location to the obturator under a vascular bundle. Given the neurovascular and anatomic and complexity of this area, it is advisable unless one is extremely comfortable with groin dissection to perform these procedures with an orthopedic oncologist who is inured to operating in this area. Regardless of the positive results reported, patients must be aware that, in spite of embarking on a rather heroic procedure, they may still have persistence of their pain, albeit less. They still may require secondary therapies and they still may have some degree of functional limitation even after attempting remediation.
These procedures are not for the faint of heart. They are also clearly indicated in an effort to salvage a relatively uncommon complication that can be exquisitely disrupting to quality of life of patients.