Quebec's college of physicians to investigate surgeries that remove incontinence sling

Quebec's college of physicians is launching an inquiry into how surgeries to remove an incontinence sling are being performed in the province.

An investigation by Radio-Canada's Enquête found 31 women who had been implanted with suburethral slings felt the need to have the devices surgically removed in the United States — because they no longer trusted that urologists in Quebec could perform the surgery properly. 

Every year, 11,000 women get sling implants in Canada to deal with incontinence. The slings are not meant for removal. They graft themselves quickly to tissue, muscle and sometimes bone, so when complications occur, recovery can be fraught with pain and pitfalls.

Studies show between 350 and 400 of those women will need to have their slings removed, either partially or completely.

In Quebec, partial withdrawals are more common. If, however, severe pain begins immediately after the implant, or is present on both sides of the hips, groin or legs, a complete sling withdrawal may be required. And that is where things get complicated.

'Intense pain'

In November 2017, Lise Brouillard had a sling — made of plastic mesh — implanted under her urethra. She began to experience extreme pain almost immediately.

"Right out of surgery, I had an intense pain like I had never felt in my life," she told Enquête.

The complications from suburethral slings are clearly outlined in both manufacturers' brochures and Health Canada advisories, but in many cases, health professionals fail to recognize the symptoms when they occur.

In the seven months following Brouillard's surgery, she was referred to a neurologist, a physiotherapist, an orthopedist, an osteopath, an acupuncturist and a specialist in sports medicine without anyone ever making the connection between her pain and the implanted sling.

According to the Régie de l'assurance maladie du Québec (RAMQ), there are urologists in Quebec capable of completely removing the slings, but very few.

Brouillard went to one at the Jewish General Hospital to have hers completely removed. The sling had pierced her vaginal wall and seemed stuck to a nerve. After the surgery, Brouillard continued to feel some discomfort.

"There was something pulling right and left and I felt like an inflammation of the groin down the left leg. It was constant and sometimes painful," she said.

Brouillard's surgeon told her all but one centimetre of the sling had been removed and it was likely not the cause of the discomfort.

After requesting her pathology report, she discovered only five centimetres — of a sling that usually measures around 20 centimetres — had actually been removed. She challenged her surgeon, who repeated his claim.

"You have to stop overreacting … I guarantee you it's not the sling … there is one centimetre … on the right … and on the left side, there is absolutely nothing," the urologist told Brouillard, in a recording obtained by Enquête.

"For what little remains of the sling, forget about it."

Brouillard decided instead to get the sling fully removed by a doctor in St. Louis, Mo.

Uro-gynecologist Dionysios Veronikis operated and found an additional seven centimetres on the left and 10 centimetres on the right — a total of 17 centimetres the Quebec urologist had not removed.

Brouillard's urologist in Quebec did not respond to requests for an interview.

Not an isolated case

Brouillard isn't the only woman in the province to deal with similar issues.

Cynthia Gagné also turned to Dr. Veronikis after consulting several Quebec urologists. One offered to completely remove the sling, but since the doctor had few operations under her belt, Gagné chose instead to go to Missouri.

She started a support group on Facebook, now with nearly 600 members, all women who say they have experienced complications related to their slings. Over the last few months, 31 of them have, like Gagné, travelled to the United States to have their slings removed by Dr. Veronikis.

Gagné does not question the general competence of Quebec urologists. She asks only that their lack of experience in complete sling withdrawals be recognized.

According to recordings obtained by Enquête​​​​​​, a Quebec urologist often referred to for full sling removals at the Centre hospitalier universitaire de Sherbrooke claims a fully removed sling measures between 11 and 13 centimetres. 

Urologist Xavier Game, a leading expert in sling removals in France, estimates that the 50 or so slings he has removed measured between 15 to 20 centimetres.

Enquête also consulted the pathology reports of the 30 Quebec women who were operated on in the United States. On average, the length of the slings removed by Dr. Veronikis measure between 20 to 23 centimetres.

Investigation launched

Now, Quebec's college of physicians says it is launching an investigation into the removal of the slings.

"The concept was to put it on a lifetime basis. It was not designed in order to remove them," said Dr. Yves Robert, the secretary of the college.

"The real issue is to try to discover how to handle that and remove them when there is a complication, and there's no real international consensus on this issue."

The goal of the inquiry is to identify the nature of the health problems, review the literature, consult with experts and establish a plan to investigate the symptoms experienced by patients.

Gagné wants the women who go to the United States for their surgeries to be reimbursed by Quebec's health insurance board.

The Quebec Urological Association refused to answer questions or grant an interview.

In a letter, they wrote that "sling implants positively transform the lives of patients with incontinence and greatly improve their quality of life." 

They added that "in certain cases, a partial removal of the sling can be necessary and this procedure can be performed by many urologists. In the far more rare cases where a full removal of the sling is required, our patients do not need to go elsewhere for this procedure. This type of surgery has been performed successfully in Quebec."