Vaginocutaneous Fistula, a Long-Term Complication of Transobturator Tape Procedure

INTRODUCTION: The midurethral sling (MUS) is considered the gold standard surgical management of stress urinary incontinence (SUI). Studies have shown that the retropubic and transobturator (TOT) approaches are comparable in efficacy and safety profiles for treatment of SUI. However, the two approaches each have unique complications, which should guide postoperative monitoring. Retropubic slings have been associated with greater risk of bladder, urethral, and bowel injuries, urinary tract infections, vascular injuries, and voiding dysfunction requiring surgical revision. TOT slings have a lower risk of bladder or bowel injury, but an increased risk of pelvic neuropathy and groin pain. Mesh erosion and exposure has been reported in roughly 2–4% of patients with long-term follow-up for both approaches. However, long-term complications are expected to be underreported due to loss to follow-up. To this end, this case report describes a case of vaginocutaneous fistula discovered in a patient 9 years after placement of TOT sling. Although rare, this detrimental complication urges clinicians to consider the formation of a vaginocutaneous fistula as a differential diagnosis in a patient with history of TOT sling complaining of vaginal discharge and groin pain. OBJECTIVE: Our objective is to provide a case-based format to the evaluation and management of vaginocutaeous fistula following TOT sling placement. METHODS: A 58-year-old female with malodorous vaginal discharge and bleeding following TOT sling placement. Medical history was notable for a 60-pack-year smoking history and recurrent upper thigh abscesses requiring repeated incision and drainage. MRI was obtained that demonstrated vaginocutaneous fistula involving the previously placed TOT sling. The patient was counseled and elected to undergo surgical management. Methylene blue was injected into the cutaneous portion of the fistula, confirming diagnosis and locating the vaginal portion of the fistula. A paramedian vaginal incision was made left lateral to the fistulous tract opening. The TOT sling was identified and dissected to the level of the left obturator foramen then removed. Dissection was extended to the contralateral side then excised. The incised tissue was closed in layers with absorbable suture. RESULTS: The cutaneous portion of the fistula allowed passage of an index finger to 3 cm and passage of a 3-mm Hegar dilator to the level of the obturator membrane. The excised portion of the transobturator mesh sling was found to measure 10.5 cm. At 6-week post-op follow-up, the patient reported resolution of drainage, and the fistulous tract was confirmed to be occluded. CONCLUSIONS: This case demonstrates the evaluation and management of a rare long-term complication of a TOT sling. The fistulous tract resolved following excision of the offending portion of the sling without the need for more aggressive surgical management. Risk factors that led to the development were the patient’s tobacco use history, potentially incorrect placement of one of the sling arms, and repeated incision and drainage of an associated abscess.