Vaginal Erosion After Pubovaginal Sling Procedures Using Dermal Allografts

Case 1. A 64-year-old woman was referred with complaints of bloody vaginal discharge, pelvic pain and vaginal prolapse 10 weeks after a pubovaginal sling procedure and cystocele repair using a Repliform (Boston Scientific, Natick, Massachusetts) dermal allograft and abdominally placed bone anchors. Medical history included hysterectomy and 2 cystocele repairs. Physical examination revealed suprapubic tenderness, granulation tissue on the anterior vaginal wall and prolapse of the vaginal apex to the hymen. Cystoscopy, pelvic x-ray and bone scan were normal. Vaginal estrogen treatment did not resolve the symptoms. The patient underwent transvaginal exploration, partial graft excision, and cystocele and enterocele repair. Pathological examination of the excised graft material revealed benign granulation tissue. At 6 months of followup the patient was asymptomatic and continent without recurrent vaginal erosion or prolapse. Case 2. A 39-year-old woman presented with irritative bladder symptoms, vaginal discharge and suprapubic pain 20 weeks after a pubovaginal sling procedure and cystocele repair using a Repliform dermal allograft and abdominally placed bone anchors. Medical history was otherwise unremarkable. Physical examination revealed suprapubic tenderness, granulation tissue on the anterior vaginal wall and a fixed proximal urethra high in the retropubic space (fig. 1). Pelvic magnetic resonance imaging and bone scan showed no evidence of osteitis pubis or osteomyelitis. Cystourethroscopy was normal. Elevated detrusor pressure during voiding on urodynamic tests suggested urethral obstruction. The patient underwent transvaginal exploration, complete graft excision and urethrolysis (fig. 2). The bone anchors were not removed. Pathological evaluation of the graft material revealed fibrovascular tissue with increased fibrosis. At 8 months of followup the patient had no recurrent vaginal erosion. Irritative bladder symptoms resolved and she reported mild stress urinary incontinence.