Female Stress Urinary Incontinence (SUI) is a very common problem. Prevalence rates  are wide-ranging (4-33%), due to heterogeneity in methodology, definition of UI and the populations included. The gold standard surgery for SUI since 1996 has been  polypropylene Tension  Free Vaginal  Tapes (TVT). These are placed under the urethra with different techniques; retropubic, transobturator and single incision. Due to serious complications related to meshes in general and malplaced TVT; the usage of TVTs is considerably restricted through regulations imposed by health authorities in many countries. TVT is associated with complications (Ref. 1 & 2) bladder perforation, urethral invasion and vaginal erosions. In Sweden 2020, 2302 TVT procedures were done of which 1243  were retropubic TVT ( Swedish National Quality Register Of  Gynecological Surgery)(Ref.3).  With retropubic TVT procedure, cystoscopy is mandatory, because of risk for bladder perforation which can be easily corrected by repositioning the tape, during the operation, without any detrimental consequences. The video film shows how pelvic floor ultrasound can aid in the diagnosis of mesh complications and the consequences of  peroperative missing a bladder perforation!

Case report: A 36 years old healthy multipara presented with symptoms of SUI, and  was operated under local anaesthesia and sedation with a retropubic TVT. Post operatively she experienced only an marginal improvement in her SUI but developed urgency , suprapubic pain with full bladder, painful badder emptying which accentuated to  a grating sensation of her bladder  moving on barbed wire at  the end of bladder emptying! She was treated with  analgesic and antimuscarinic medications for pain and urgency , with marginal improvement. With 3D ultrasound of bladder a TVT was found inside the bladder and cystoscopy confirmed the free lying tape which hanged down from the bladder roof towards the left of midline. Peroperatively, the left arm of TVT was found adherent  to the anterior surface of the bladder wall and perforated the detrusor from bladder roof.

Post operatively patients urgency, lower abdominal pain with bladder filling and painful bladder emptying disappeared. Urodynamics showed SUI and the patient was offered transobturator TVT.  Pelvic floor ultrasound , 2D and 3D is helpful in the diagnosis of mesh complications.

Symptoms of dysuria, urgency, painful bladder emptying , urinary tract infections and bladder stones after a TVT  operation should be investigated with cystoscopy to  exclude underlying problem with misplaced  TVT.

Jahn J, Reisenauer C, Schoenfisch B, Amend B, Brucker SY, Andress J. A retrospective analysis of perioperative complications associated with retropubic tension-free vaginal tape in 960 women. Arch Gynecol Obstet. 2022 Feb;305(2):407-413. doi: 10.1007/s00404-021-06299-x. Epub 2021 Oct 28. PMID: 34709448; PMCID: PMC8840912.
Fusco F, Abdel-Fattah M, Chapple CR, Creta M, La Falce S, Waltregny D, Novara G. Updated Systematic Review and Meta-analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence. Eur Urol. 2017 Oct;72(4):567-591. doi: 10.1016/j.eururo.2017.04.026. Epub 2017 May 4. PMID: 28479203.
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