Delayed Vesicocutaneous Fistula 18 Years After Tension-Free Vaginal Tape: A Rare Case Report

A 65-year-old woman, para 4 with four previous vaginal deliveries, presented with a history of multiple comorbidities, including diabetes mellitus for 7 years and hypertension for 5 years. Her diabetes was managed with insulin and was poorly controlled, with a glycated haemoglobin (HbA1c) level of 9.9%. Her hypertension was controlled with methyldopa. There was no documented history of impaired wound healing, chronic kidney disease, or other conditions known to compromise tissue repair. She had previously undergone a total abdominal hysterectomy for adenomyosis 20 years earlier. Subsequently, she developed anterior vaginal wall prolapse and SUI. The stage of prolapse at the time of TVT insertion could not be determined due to incomplete access to previous hospital records. She underwent a TVT procedure 18 years earlier at another hospital in India. Eighteen years following TVT placement, she presented with continuous urinary leakage from the lower abdominal surgical scar. Computed tomography (CT) of the abdomen and pelvis demonstrated a well-defined, curvilinear, tortuous, elongated vesicocutaneous fistulous tract measuring approximately 9 cm in length and 5 mm in diameter. The tract originated from the skin surface of the lower anterior abdominal wall at the site of the previous surgical scar. It extended deeply through the postoperative scar tissue, traversing the rectus muscle into the right paramedian region. It communicated with a diverticular outpouching arising from the right anterolateral wall of the urinary bladder, confirming a fistulous connection between the bladder and the cutaneous surface. A small intrasinus fluid collection was noted, with no evidence of a significant pelvic abscess or collection. Cystoscopic examination demonstrated erosion of the polypropylene TVT mesh into the bladder lumen through the anterior bladder wall. The exposed mesh was visualised at the site of erosion, with surrounding inflammatory mucosal changes, confirming intravesical TVT mesh erosion as the underlying cause of the vesicocutaneous fistula. Prior to surgical intervention, a Foley catheter was inserted to ensure continuous bladder drainage and facilitate healing. The patient subsequently underwent exploratory laparotomy, during which the fistulous tract between the anterior bladder wall and the abdominal wall was identified ( Figure 1 ). The eroded TVT mesh was removed, and the fistulous tract was excised ( Figure 2 ). The bladder defect was repaired in two layers using absorbable polyglactin 910 (Vicryl ® ) 2/0 sutures. The first layer consisted of a continuous watertight closure of the bladder mucosa and muscular layer, followed by an interrupted seromuscular imbricating layer to reinforce the repair and minimize the risk of leakage. The repair was tested intraoperatively for water tightness. The abdominal wall defect was subsequently repaired with layered closure, and adequate bladder drainage was maintained postoperatively with a Foley catheter to facilitate healing. Postoperatively, she received antibiotics, analgesics, and thromboprophylaxis. She was discharged after two days with advice to avoid heavy lifting, straining, and sexual intercourse for six weeks and to practice gentle ambulation. The Foley catheter was maintained for two weeks to provide continuous drainage and promote healing of the repaired bladder wall. Figure 1 Intraoperative image showing vesicocutaneous fistula repair. The bladder was opened through the fistulous tract, the incision was extended, and the retained tape, along with the fistulous tract, was excised. Intraoperative view of vesicocutaneous fistula repair showing excision of retained tape through the opened bladder. A surgical incision is retracted open, exposing the operative field. Multiple surgical instruments hold the tissues apart while the bladder is opened through the fistulous tract. A retained tape is identified within the surgical field and is excised together with the fistulous tract after the bladder incision has been extended. Surrounding soft tissue, adipose tissue, and surgical gauze are shown. Figure 2 Excised specimen showing the vesicocutaneous fistula tract with the retained tape. Following complete surgical removal. Excised vesicocutaneous fistula tract with retained tape displayed on a sterile surgical drape after removal. Postoperative photograph of the excised vesicocutaneous fistula specimen placed on a sterile blue surgical drape. The retained tape remains attached to the excised fistulous tract and is held with a surgical clamp. The specimen includes the fistula tract with surrounding soft tissue and yellow adipose tissue, demonstrating complete removal of the retained tape and associated fistulous tissue. Several surgical instruments, including forceps, a scalpel handle, and clamps, surround the specimen. Intraoperative image showing vesicocutaneous fistula repair. The bladder was opened through the fistulous tract, the incision was extended, and the retained tape, along with the fistulous tract, was excised. Excised specimen showing the vesicocutaneous fistula tract with the retained tape. Following complete surgical removal. Four weeks after catheter removal, the patient developed recurrent stress urinary incontinence. Clinical examination revealed Stage III anterior vaginal wall prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system. During the six-month healing period following fistula repair, she was advised to perform pelvic floor muscle exercises and use topical vaginal estrogen therapy to optimize tissue quality and pelvic floor support. Six months after fistula repair, she underwent anterior colporrhaphy with Kelly plication, resulting in complete resolution of urinary incontinence. At eight weeks of postoperative follow-up, she remained asymptomatic. This case highlights the importance of a staged management approach in patients presenting with delayed TVT-related bladder erosion and vesicocutaneous fistula. The clinical course of the patient is summarized in Table 1 . Table 1 Timeline of Clinical Events Time/Year Event Intervention/Outcome 20 yrs ago Total abdominal hysterectomy for adenomyosis Recovered 18 yrs ago TVT for stress urinary incontinence Symptom resolution 1 yr ago Leakage from the abdominal incision CT & cystoscopy: vesicocutaneous fistula Surgery date TVT removal + fistula repair Recovered, Foley 2 weeks 4 wks post-repair Recurrent SUI Stage III anterior wall prolapse 6 mo post-repair Anterior colporrhaphy and Kelly Plication Complete continence 8-wk follow-up Asymptomatic Doing well Timeline of Clinical Events

Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine during physical exertion, such as effort, sneezing, or coughing. 1 It affects a large proportion of the female population, with an estimated 35% experiencing such symptoms during their lifetime. 2 SUI is one of the most common pelvic floor disorders affecting women and can substantially impair quality of life, physical activity, sexual function, and psychosocial well-being. 2 Ulmsten and Petros were the first to describe the Tension-free Vaginal Tape (TVT) procedure in 1996. Since then, it has become the most commonly performed procedure for managing SUI. 3 The TVT procedure involves the placement of a polypropylene mesh tape beneath the mid-urethra to provide support during increases in intra-abdominal pressure, thereby restoring continence while preserving normal voiding function. 3 Several studies have assessed the safety and success rates of this procedure, but there is still insufficient data on the occurrence of complications and their management. 4 Patients with comorbidities such as diabetes and vascular diseases are at a higher risk of developing complications. 5 Postoperative complications can include voiding dysfunction, retropubic hematoma formation, new-onset urinary urgency, and mesh erosion into the vagina, urethra, or bladder. Tape erosion into the bladder has been reported in 0.5–0.6% of cases. 6 Although mesh erosion can occur at any time after TVT implantation, most cases are diagnosed within the first few years following surgery. Published reports of intravesical tape erosion describe variable intervals between implantation and diagnosis, with most cases reported during the early postoperative years. 7 Delayed presentations occurring more than 10 years after implantation are exceptionally uncommon and have mainly been described in isolated case reports. These late complications are thought to result from chronic mesh–tissue interaction, including persistent inflammatory responses, foreign-body reaction, gradual tissue remodeling, and progressive erosion into adjacent organs. 7–10 Intravesical mesh erosion may present with recurrent urinary tract infections, hematuria, bladder stone formation, persistent lower urinary tract symptoms, and, in rare cases, progression to fistula formation. 11 Vesicocutaneous fistula is an abnormal communication between the urinary bladder and the skin, resulting in continuous urinary leakage through the cutaneous opening. 11 It is a rare urological condition that is most commonly associated with pelvic trauma, malignancy, radiation therapy, chronic infection, or previous pelvic surgery. 12 Vesicocutaneous fistula secondary to delayed TVT mesh erosion is exceedingly uncommon, with only isolated cases reported in the literature. 13 This case report describes an exceptionally delayed presentation occurring 18 years after TVT implantation, culminating in vesicocutaneous fistula formation secondary to chronic intravesical mesh erosion. The unusually prolonged interval between surgery and presentation highlights the risk of very late mesh-related complications and underscores the importance of sustained long-term clinical vigilance. Clinicians should consider delayed mesh erosion in women presenting with persistent urinary symptoms, recurrent urinary tract infections, or unexplained suprapubic sinus formation, even many years after anti-incontinence surgery. 13

Vesicocutaneous fistula following TVT insertion is an exceptionally rare but serious delayed mesh-related complication. Chronic mesh–tissue interactions, including persistent inflammatory responses, foreign-body reaction, and gradual tissue remodeling, together with patient-related factors such as diabetes and age-related estrogen deficiency, may contribute to progressive mesh erosion and fistula formation even years after an initially successful procedure. Clinicians should recognize that mesh-related complications may present long after TVT implantation. They should consider delayed mesh erosion in women presenting with persistent urinary symptoms, recurrent urinary tract infections, pelvic pain, hematuria, or unexplained suprapubic leakage. This case highlights the importance of long-term clinical awareness, patient education regarding potential late complications, and individualized follow-up after TVT procedures, particularly among patients with comorbidities that may impair tissue healing. Although the optimal duration and structure of surveillance remain to be established, maintaining a high index of suspicion and timely diagnostic evaluation are essential for early recognition and appropriate management of delayed mesh-related complications.

Minimally invasive procedures using synthetic materials for the management of stress urinary incontinence have gained popularity due to their high effectiveness; however, they can lead to complications that are uncommon with native tissue repairs. 7 The tension-free vaginal tape TVT procedure, for instance, involves placing a synthetic polypropylene mesh beneath the mid-urethra to relieve SUI. This tape reinforces the vaginal hammock, supporting the function of the pubourethral ligaments and levator ani muscles, thereby improving continence. 3 Urethral or bladder erosion is a recognised complication of the TVT procedure. It may present with hematuria, increased urinary frequency, urgency, pelvic or vaginal pain, recurrent urinary tract infections, or urine leakage through the surgical incision. 9 One possible contributing factor to vesicocutaneous fistula formation is an unrecognised intraoperative bladder perforation, which may occur due to inadequate bladder distension and result in the tape being obscured by mucosal folds. Although this was not the case in our patient, it remains a recognised mechanism for fistula development in other cases. Another mechanism could be pressure necrosis resulting from elevated intra-abdominal pressure and unrecognised submucosal placement of the tape, which may gradually penetrate the bladder wall. 8 Mesh implantation triggers a foreign body reaction mediated primarily by macrophages. In women with diabetes, impaired macrophage function, excessive inflammation, reduced angiogenesis, dysfunctional fibroblasts, and altered collagen remodeling compromise tissue integration of the mesh. These factors contribute to poor healing, chronic inflammation, and fibrosis, thereby increasing the risk of mesh-related complications, including erosion. 14 , 15 Low estrogen leads to thinning of the bladder urothelium, resulting in a more fragile bladder lining. This makes the bladder more susceptible to trauma or erosion from foreign bodies, such as synthetic mesh. 16 Our patient had uncontrolled diabetes and age-related estrogen deficiency, as evidenced by symptoms such as vaginal dryness, dyspareunia, and urinary frequency. These systemic and local tissue factors likely contributed to poor healing and increased susceptibility to mesh erosion. Although the patient developed a late vesicocutaneous fistula, this does not necessarily reflect poor surgical technique, as late fistulas are often the result of chronic mesh-tissue interactions and patient-related risk factors, which can lead to gradual erosion despite correct sling placement. 17 This delayed presentation often complicates diagnosis, and when the tape comes into contact with urine, encrustation may develop, further exacerbating urinary symptoms. 18 Previously reported cases of delayed TVT-related complications have described intravesical mesh erosion occurring months to several years after implantation, with clinical presentations including recurrent urinary tract infections, hematuria, bladder stone formation, and persistent lower urinary tract symptoms. 6 , 11 However, progression from intravesical mesh erosion to vesicocutaneous fistula formation is exceedingly rare, with only isolated cases reported in the literature. 11 Most reported cases of bladder erosion have been managed with removal of the eroded mesh, either through endoscopic or open surgical approaches, with repair of the affected urinary tract when required. 13 In contrast, our patient developed a vesicocutaneous fistula 18 years after TVT implantation, representing an exceptionally delayed presentation. The prolonged interval between implantation and fistula formation highlights the potential role of chronic mesh–tissue interaction, persistent inflammatory response, foreign-body reaction, tissue remodeling, and progressive erosion into adjacent structures over many years. 14 This case expands the clinical spectrum of late TVT-related complications and emphasizes the importance of considering delayed mesh erosion in women presenting with unexplained urinary leakage or suprapubic sinus formation, even decades after anti-incontinence surgery. Despite these potential complications, evidence suggests that TVT is generally safe when performed correctly. A systematic review and meta-analysis found no reported cases of delayed cutaneous infection following TVT insertion. 19 Furthermore, two long-term follow-up studies spanning 11 years and involving a total of 237 women reported no long-term adverse outcomes, including the absence of vaginocutaneous fistulas or abscesses. 20 , 21 These findings indicate that the risk of severe or delayed complications is minimal when the procedure is executed properly. Nevertheless, complications related to the synthetic material and surgical technique are increasingly observed. These issues are often amplified when surgeons underestimate the complexity of the procedure, leading to technical errors and adverse outcomes. 7 The wide variation in erosion or extrusion rates is influenced by factors such as operative technique, implant size, and the specific properties of the sling material, including small mesh pore size, stiffness, local ischemia, poor tissue irrigation, reduced elasticity, inadequate mesh incorporation, subclinical infection, and overall tissue compatibility. 10 Moreover, patient-related factors also play a significant role. Poor tissue quality, atrophy (commonly due to estrogen deficiency), impaired healing, or infection can compromise the tissue covering the mesh, increasing the risk of erosion into adjacent structures. This risk is particularly relevant in older patients with comorbidities, as tissue integrity and healing capacity may already be compromised. 22 Even years after initially successful TVT surgery, patients should be monitored for symptoms such as urine leakage, recurrent UTIs, or pelvic pain, which may indicate delayed mesh erosion or fistula formation requiring prompt management.

This report describes a single case, which limits the generalizability of the findings. Details of the initial TVT procedure, including operative information and the initial prolapse stage, were unavailable due to incomplete records from the previous hospital. Long-term follow-up data on the interval between TVT insertion and symptom onset were also unavailable, limiting assessment of the exact timeline and contributing factors to fistula development. The potential roles of diabetes and estrogen deficiency are inferred from clinical findings and established pathophysiology; however, a direct causal relationship cannot be confirmed.