Indications and risk factors for midurethral sling revision

Mesh Extraction Surgery and Laser Treatment for Pain After Mid-Urethral Sling Surgery: A Case Series

Stress urinary incontinence (SUI) is the leakage of urine due to abdominal pressure. The primary surgical approach involves the insertion of a mid-urethral sling (MUS) with a mesh, which can occasionally lead to post-operative pain. To address complications, MUS removal is often necessary. We hypothesize that a non-ablative erbium:yttrium aluminum garnet (Er:YAG) laser combined with vagina (vaginal erbium laser (VEL)) and urethra (urethra erbium laser (UEL)) treatments could be a post-MUS removal option. A study involving laser treatment started in 2016 for women with recurrent SUI one year after MUS removal who were not affected by pelvic floor muscle exercises and who did not wish to have MUS reinsertion or urethral injection treatment. Five patients (mean age, 54.5 ± 9.35 years) were enrolled, all receiving laser therapy. The visual analog scale (VAS) was used to assess pain as a primary endpoint, and the one-hour pad test was performed for SUI as a secondary endpoint. The mean pain VAS score changed from 8.57 ± 0.69 to 2.29 ± 1.50 (p = 0.00002) after MUS removal. Furthermore, the VAS score was 0 (p = 0.0034) after VEL + UEL. SUI changed from 4.42 ± 2.9 g on the one-hour pad test during MUS insertion to 66.7 ± 39.0 (p = 0.005) after removal. However, after the VEL + UEL treatment, it was 3.71 ± 5.25 g (p = 0.0035). The pathological tissue collected from the five patients at the time of MUS removal surgery had vacuolization in the part where the artificial material was present in the specimen, with foreign-body giant cells proliferated around it. One year after the MUS removal, mucous membrane regeneration was poor, and tissue thickness was thin. One year after the VEL + UEL treatment, the tissue had normalized mucosa, and there was no inflammation. Our study suggests MUS extraction and VEL + UEL as viable options for treating MUS pain in women.

Sexual dysfunction in patients after cystocele surgery. Is the g-spot a myth or reality?

The anterior wall of the vagina is very rich in nerves, blood vessels, and exocrine glands. This anatomical region is related to female sexual desire. During the anterior colporrhaphy operation, dissection of the anterior vaginal wall causes damage to this area, which may lead to decreased sexual satisfaction. In the present study, we aimed to investigate sexual function after anterior vaginal wall surgery.

METHODS

Totally 89 patients who had undergone the anterior colporrhaphy operation between May 2021 and December 2021 were included in the study. The patients' sexual function was investigated before surgery and six months after surgery. The effects on sexual function were determined according to the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.

RESULTS

According to our study results, orgasm and orgasm intensities decreased after anterior colporrhaphy surgery (p = 0.000; p = 0.000), while sexual desire or arousal did not change (p = 0.405; p = 0.052). In addition, an increase in pain was observed during sexual intercourse after surgery (p = 0.000). No statistically significant difference was observed in the PISQ-12 score before or after anterior colporrhaphy surgery (p = 0.675).

CONCLUSION

Based on the results of our study, we found a remarkable decrease in orgasm in these patients. Furthermore, we think that it is appropriate to recommend conservative or alternative treatments for the early stages of cystocele. Nevertheless, larger-scale studies may be designed to reveal the importance of this region in sexual function.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

OBJECTIVES

The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence.

METHODS

We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure.

RESULTS

Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04).

CONCLUSION

The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Pain resolution and functional outcomes of total mesh excision: a case series

INTRODUCTION AND HYPOTHESIS

The objective was to assess the impact of total excision of polypropylene midurethral slings (MUS) on patient pain levels and to report on functional outcomes including recurrent/de novo stress urinary incontinence (SUI), sexual function, and quality of life measures.

METHODS

This is a retrospective analysis of patients who underwent total MUS excision from March 2017 to December 2019. The primary outcome was the impact on pain assessed by a Numeric Rating Scale (NRS). Questionnaires analyzed were: Pain Catastrophizing Scale, Pelvic Floor Distress Inventory Short Form-20, Female Sexual Function Index, and McGill Pain Index questionnaires.

RESULTS

Thirty-two women underwent total mesh excision within the inclusion period; with follow-up data available for 31 out of 32; 14 (43.8%) had previously undergone one or more partial vaginal mesh excision procedures. Types of MUS removed were: 14 (43.8%) transobturator midurethral slings, 12 (37.5%) retropubic midurethral slings, 4 (12.5%) mini-slings, and 2 (6.3%) mesh slings placed by laparotomy. Pain was the main reason for referral in 31 patients (96.9%). Mean pain NRS reduced from 6.1 pre-operatively to 3.3 post-operatively, with paired comparison showing a significant difference (p<0.01). Qualitatively, complete symptoms resolution was observed in 10 out of 31 (32.3%), another 9 out of 31 (29.0%) patients experienced clinically significant improvement, 2 out of 31 (6.5%) did not experience improvement in pain, and 10 out of 31 (32.3%) reported new/worsening pain. Post-operative complications occurred in 9 (29.0%) patients; all were Clavien-Dindo grade II. Nineteen (61.3%) reported de novo/recurrent SUI post-operatively.

CONCLUSION

Total MUS mesh excision yields high complication and SUI recurrence rates, counter-balanced by a 61.3% pain resolution/improvement rate. These data are pertinent for patient counseling.

Translabial Ultrasound: An Effective Modality for Evaluation of Midurethral Sling Revision

ABSTRACT

Midurethral sling (MUS) surgical procedures, in which a polypropylene synthetic mesh graft is transvaginally placed to support the urethra and manage stress urinary incontinence (SUI), is commonly performed ( Urology. 2013;82(1):38-41; Radiology. 2018;289(3):728-729). Within 10 years of sling placement, about 1 in 20 women undergo subsequent surgery to revise their mesh, in which the mesh is cut or partially excised ( Obstet Gynecol . 2019;133:1099-1108). Translabial ultrasound (TLUS) has been described as a sensitive technique for viewing MUS, although few studies have evaluated its ability to view surgically revised MUS ( Radiology . 2018;289(3):721-727). Understanding the anatomy of the MUS is critical to urologists and urogynecologists striving to optimize management of patients presenting with lower urinary tract symptoms and history of MUS. To assess the clinical utility and reliability of TLUS as a diagnostic tool in its detection of MUS discontinuity, we conducted a retrospective analysis on patients who underwent TLUS at a tertiary care center between September 2017 and May 2020 for indication of lower urinary tract symptoms and history of MUS placement. Performance of TLUS was evaluated by comparing findings with operative or clinical records. Among the 81 women included, detection of MUS revision, which was defined as a discontinuity in sling material, had a sensitivity of 84.6% and specificity of 97.1%. Translabial ultrasound is an inexpensive, nonirradiating, and noninvasive modality that is effective at visualizing MUSs. It is a reliable identifier of previous MUS revision, in which it detects a midline discontinuity of the hyperechoic mesh with an average 10 mm gap.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Incidence of Midurethral Sling Revision or Removal by Its Timing With Prolapse Surgery

OBJECTIVE

The aim of the study was to evaluate incidence of midurethral sling removal/revision based on timing with surgery for pelvic organ prolapse.

METHODS

This was a retrospective cohort study of women who underwent midurethral sling placement in a claims-based database of women 65 years or older. Three groups were identified using the Current Procedural Terminology codes: (1) isolated sling, (2) concomitant sling, and (3) prolapse surgery and staged sling after prolapse surgery. In the staged group, placement of sling was identified within 18 months after index prolapse surgery. Fascial grafts were excluded. Sling removal/revision was identified across 3 years after sling surgery using Current Procedural Terminology code 57287. Rates of sling removal/revision were calculated by group. Comparisons were made using the χ2 test and analysis of variance. Cumulative incidence of removal/revision was evaluated using the Kaplan-Meier curves. Cox proportional hazards was performed to evaluate factors influencing removal/revision.

RESULTS

We identified 39,381 isolated MUSs, 25,389 concomitant, and 886 staged. The rate of sling removal/revision was 3.52%. Rates of removal/revision differed between groups (7% staged vs 3.94% concomitant vs 3.17% isolated sling, P < 0.001). Compared with the staged group, the rate of removal/revision was lower in the isolated sling group (relative risk, 0.4550; 95% confidence interval [CI], 0.358-0.568) and the concomitant group (relative risk, 0.5666; 95% CI, 0.4450-0.7287). After adjusting for patient characteristics, sling revision or removal remained significantly less in the isolated MUS (hazard ratio, 0.50; 95% CI, 0.39-0.65) and concomitant (odds ratio, 0.55; 95% CI, 0.43-0.71) groups.

CONCLUSIONS

Sling removal/revision is higher when it is staged after prolapse surgery compared with isolated and concomitant placement. Future studies are needed to confirm these findings in a controlled population.

Pain after midurethral sling; the underestimated role of mesh removal

Introduction

The primary aim of this study was to evaluate the results of midurethral sling (MUS) removal in women who have pain as their single complication of MUS.

Material and methods

We performed a retrospective chart study supplemented with a cross sectional questionnaire. Women who underwent MUS removal for pain as the solitary reason for removal between 2004 and 2018 were included. Primary outcome was change in pain levels assessed by the visual analogue scale (VAS) pain score (range 0–10). Secondary outcome was the recurrence of stress urinary incontinence (SUI).

Results

Twenty-six of 31 patients returned the questionnaire. Median medical file follow-up was 12 months (range 2–66) and 25 months (range 5–104) regarding questionnaires. VAS pain score dropped from 7.8 (SD 1.9) at baseline to 4.5 (SD 3.2) at follow-up (p <.00). Seven (23%) patients were pain-free. Patients undergoing partial vaginal resection (n = 6) had a VAS pain score decrease of 4.7 (p = .02) versus 2.7 (p = .02) for complete vaginal removal (n = 14). Twenty-three (89%) patients experienced SUI at follow-up, whereof 10 (45%) reported (almost) no incidents of SUI.

Conclusions

MUS removal is a viable and safe option with a significant drop in VAS pain score in patients with chronic pain after MUS placement. A post-operative increase of SUI and a possible renewed wish for SUI treatment have to be considered. This should not be a reason to refrain from information and/or referral for surgical removal.

Predictors of further anti-incontinence interventions or transvaginal urethrolysis after a pubovaginal sling procedure in women with and without neurologic disorders

BACKGROUND/PURPOSE

The impact of neurologic disorders on the clinical outcome of suburethral sling procedures has seldom been studied. Our aim is to elucidate factors predicting further anti-incontinence interventions or transvaginal urethrolysis after a re-adjustable pubovaginal sling procedure (PVS), especially in patients with neurologic disorders.

METHODS

Medical records of all consecutive women who underwent re-adjustable PVS for stress urinary incontinence (SUI) were reviewed.

RESULTS

A total of 589 women were enrolled, 152 (25.8%) women were found to have persistent or recurrent SUI after surgery, and 39 (6.6%) women underwent further anti-incontinence interventions. Postoperative voiding dysfunction was found in 46 (7.8%) women, and 23 women (3.9%) underwent transvaginal urethrolysis. Low body mass index (hazard ratio = 0.92) and low functional bladder capacity (dL, hazard ratio = 0.83) were factors predicting the presence of persistent/recurrent SUI. However, the presence of spinal cord disorder (hazard ratio = 8.91) and a history of prior surgery for pelvic organ prolapse (hazard ratio = 2.51) were factors predicting further anti-incontinence interventions. A high post-void residual volume (PVR, dL, hazard ratio = 1.52) and preoperative bladder outlet obstruction (BOO, hazard ratio = 5.39) were factors predicting postoperative voiding dysfunction. Similarly, a high PVR (dL, hazard ratio = 1.50) and preoperative BOO (hazard ratio = 5.38) were factors predicting transvaginal urethrolysis. A PVR >1.51 dL was an optimal cut-off value for predicting transvaginal urethrolysis.

CONCLUSION

The presence of spinal cord disorder and prior surgery for pelvic organ prolapse were predictors of further anti-incontinence interventions after re-adjustable PVS. In addition, a large PVR and preoperative BOO were predictors of transvaginal urethrolysis after re-adjustable PVS.

Post-operative tension adjustment-A simple technical modification in mid-urethral slings (MUS) for stress urinary incontinence (SUI)

INTRODUCTION

Mid-urethral sling (MUS) surgeries have revolutionized the management of stress urinary incontinence (SUI). However, MUS is a delicate balance of tension on the mid urethral segment with a 12 % risk of failure to achieve complete continence; and up-to 20 % chance of post-operative voiding dysfunction. We propose a simple technical modification in which the long ends of the tape at suprapubic or groin area are not cut immediately and are covered with a sterile dressing. After 48-72 h post-surgery the patient is checked for continence and voiding difficulties. Following this an ultrasonographic assessment of post-void residual urine is performed. Keeping in mind these 3 criteria the tape is adjusted. After complete subjective as well as objective satisfaction the long ends of tape are cut.

MATERIAL AND METHODS

This is a retrospective analysis of women who underwent MUS surgery for the management of SUI, with our simple technical modification of tape adjustment in the postoperative period. A total of 17 patients operated by single surgeon in one year were included.

RESULTS

Our results show that 58.8 % of our patients who underwent MUS procedures required post-operative tape adjustment. The number was significantly higher in the MUS - Retropubic group (85.7 %) as compared to the MUS - Obturator group (40 %). Three patients in the MUS - Retropubic group required a second time tape adjustment. Following tape adjustment all patients had complete continence (subjective and objective), with no voiding dysfunction.

CONCLUSION

The incidence of postoperative voiding dysfunction is significant following MUS surgery for SUI. A simple technical modification of delaying the cutting of the tape for two to three days gives the opportunity for perfect tension adjustment.

A comprehensive look at risk factors for mid-urethral sling revision surgery

INTRODUCTION

The objective of this study was to identify risk factors and urodynamic parameters predictive of mid-urethral sling (MUS) revision surgery that can be used for counseling patients and individualizing risk prediction.

METHODS

Retrospective case-control analysis of 40 sling revisions performed during the 12-year study period were compared to 123 control cases that did not require revision to obtain a 1:3 case-to-control ratio. Demographic, perioperative, and urodynamic data were analyzed, with p < 0.05 as significant. Independent predictors of sling revision were assessed by binary logistic regression models, with risk expressed as adjusted odds ratios.

RESULTS

After multiple regression analysis, younger age at time of index MUS placement (aOR 0.93, 95% CI 0.88-0.97), increasing number of cesarean deliveries (CD) (aOR 2.00, 95% CI 1.01-3.96), and concomitant apical prolapse repair during index MUS procedure (aOR 4.63, 95% CI 1.34-15.93) were significant predictors of sling revision.

CONCLUSIONS

Young age at the time of placement, multiple CD, and concomitant apical prolapse repair were independent factors predictive of sling revision. Giving consideration to risk factors could improve patient counseling and surgical candidate selection.

Differences between mid-urethral sling outcomes in diabetic and nondiabetic women

AIMS

The aim is to assess whether subjects with diabetes mellitus (DM) have greater urinary retention and increased post-void residual volume (PVR) following mid-urethral sling (MUS) surgery.

METHODS

This multi-center retrospective study included patients who underwent MUS (2012-2016). Baseline data included demographics, comorbidities, urinary symptoms, urodynamics data, PVR, and responses to validated questionnaires (UDI6 and IIQ7). Intraoperative data, postoperative voiding trial results, postop questionnaires, and complications were also noted. Patients with and without DM were compared. Significance was defined as P < .05.

RESULTS

A total of 605 MUS were included, 538(89%) without DM and 67(11%) with DM, of which 69% were transobturator and 31% retropubic. No differences were seen in urinary retention and passing void trial(79% DM vs 81% non-DM; P = .72). Mean PVR at discharge was similar between groups (136 mL DM vs 139 mL non-DM; P = .922). There were no differences between groups in UDI6 and IIQ7 sum scores at baseline and 1 month. DM subjects reported more bother at baseline on certain UDI-6 and IIQ-7 items including frequent urination, leakage related to urgency, and feeling frustrated. At 3 months postop, all subjects demonstrated improvement in scores. Interestingly, patients with DM reported worse quality of life on the IIQ7 sum.

CONCLUSIONS

Among subjects with well-controlled diabetes and more comorbidities who underwent MUS there were few differences in postoperative voiding dysfunction or PVR compared to nondiabetic women. DM patients were more bothered at baseline by urge-related symptoms. Quality of life following sling surgery appears to be worse in patients with DM at 3 months based on IIQ7. This data suggests that diabetic women with lower HbA1C can be counseled similarly to these complication rates and voiding dysfunction after MUS.

Proximal location of explanted midurethral slings is associated with urinary storage symptoms

AIM

To examine the location of midurethral slings (MUS) at the time of excision to determine associations between presenting symptoms and sling location at explant.

METHODS

We performed an IRB approved, retrospective review of MUS explants between January 2011 and March 2016. Symptoms and physical examination findings were compared between women with slings explanted from the mid-urethra (MU) and women with slings explanted from the proximal urethra/bladder neck (PU/BN).

RESULTS

We included 95 consecutive women who underwent MUS explant in the analysis. Presenting symptoms included pain in 69 women (72.6%), urinary urgency in 66 (66.5%), voiding dysfunction in 55 (57.9%), urge urinary incontinence (UUI) in 41 (43.2%), stress urinary incontinence in 34 (35.8%), and recurrent urinary tract infections in 22 (23.2%). At sling explant, 2 (2.1%) slings were found at the distal urethra, 33 (34.7%) at the MU and 60 (63.2%) at the PU/BN. Women with slings explanted from the PU/BN were more likely to present with urgency (78.3% vs 54.5%; P = 0.017) and UUI (53.3% vs 27.3%; P = 0.015) and less likely to present with pain on examination (48.3% vs 75.8%; P = 0.01).

CONCLUSIONS

The majority of MUS requiring explant in this cohort were found at the PU/BN. The most common presenting symptom before MUS explant was pain, followed by urgency and voiding dysfunction. PU/BN location of MUS is likely a factor in the development of urgency and UUI in women who ultimately undergo explant.

Exploring stress urinary incontinence outcomes after sling excision for perforation or exposure

OBJECTIVE

This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS).

METHODS

A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure.

RESULTS

In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99).

CONCLUSIONS

Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.

Place of surgery in the management of post-operative chronic pain after placement of prosthetic material based on a series of 107 cases

AIMS

The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material.

MATERIAL AND METHODS

Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS).

RESULTS

The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape.

CONCLUSION

Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.

Recurrence of Stress Urinary Incontinence After Midurethral Sling Revision: A Retrospective Cohort Study

OBJECTIVES

The primary objective is to determine the relative risk (RR) of reoperation for stress urinary incontinence (SUI) recurrence after midurethral sling (MUS) division or excision. Our secondary objective is to determine the RR of SUI symptom recurrence according to differing techniques of revision.

METHODS

This is a retrospective cohort study of all women who underwent surgical revision of an MUS by the Division of Urogynecology at the Women & Infants' Hospital during a 10-year period between October 1, 2004, and October 1, 2014. Sling division technique separates the sling from the urethra enough to permit transection either in the midline or lateral to the urethra. Revision was categorized as excision if a portion or the entirety of the sling was removed. Patients who underwent any operative procedure for SUI after revision were considered to have received reoperation. Subjectively, patients were considered to have postrevision recurrence of SUI if it was reported during routine evaluation/interviews or in the incontinence severity index questionnaire.

RESULTS

There were 102 patients who underwent revision of a type 1 mesh MUS; 45 underwent sling division, and 57 underwent mesh excision. After sling division, 4.4% of the patients underwent reoperation for recurrent SUI compared with 28.1% after sling excision (RR, 0.16; 95% confidence interval, 0.04-0.65). Stress urinary incontinence symptoms recurred in 13% after sling division versus 56% after excision (RR, 0.24; 95% confidence interval, 0.11-0.52).

CONCLUSIONS

The choice of technique may be dictated by the clinical scenario, but in situations in which sling division is an option, repeat operations and symptoms of SUI occur less frequently.

Readmission and reoperation after midurethral sling

INTRODUCTION AND HYPOTHESIS

We aimed to determine the rate of readmission and reoperation for patients undergoing midurethral sling (MUS) placement for stress urinary incontinence (SUI).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify all isolated MUS placed from 2012 through 2015 using the Current Procedural Terminology 4 (CPT-4) code for MUS with or without cystoscopy (57,288 ± 52,000). The cohort was then reviewed for unplanned, related readmissions and reoperations within 30 days of MUS placement.

RESULTS

Isolated MUS was placed in 9910 patients. Fifty-eight (0.59%) patients were readmitted and 81 (0.82%) had reoperation. The most common indications for readmission were related to the urinary tract, i.e., urinary retention (27.6%), non-surgical-site-related infection (15.5%), and medical related issues (15.5%) The most common indications for reoperation were urinary tract (60.5%), gastrointestinal (7.4%), and gynecologic, i.e., examination under anesthesia (6.2%). Body mass index (BMI) was less (p = 0.001), and operative time (p = 0.014) and length of stay (LOS) (p = 0.001) longer in patients who were readmitted. Those who underwent reoperation had longer LOS than those who did not have reoperation (p < 0.001). Upon multivariate analysis, BMI <25 (all p < 0.05) and longer LOS maintained statistical significance as risk factors for those who experienced readmission or reoperation (p = 0.0406, p < 0001).

CONCLUSIONS

Isolated MUS placement has low 30-day readmission and reoperation rates. Increased LOS was associated with readmission, while increased LOS and BMI <25 were associated with reoperation within 30 days.

Complications Following the Insertion of Two Synthetic Mid-urethral Slings and Subsequent Removal

OBJECTIVE

To determine outcomes after removal of two synthetic mid-urethral slings (MUS) at a tertiary care center.

METHODS

Following IRB approval, a retrospective chart review of non-neurogenic, symptomatic women requiring re-operation after ≥2 MUS was performed. Data reviewed by a third party included: demographics, prior anti-incontinence surgery, complications, pelvic/urinary symptoms, subsequent investigations, surgical repair and outcomes (including UDI-6/IIQ-7 questionnaires) at a minimum 6 months follow-up. Cure was defined as being continent, no dyspareunia, and no additional surgical therapy.

RESULTS

Between 2007 and 2014, 21 women met the inclusion criteria. Mean age was 57 years (range: 40-82) and mean follow-up was 30.2 months (range: 6-78). The majority of patients presented with one or more symptoms of voiding dysfunction (95%), urinary incontinence (86%), irritative voiding symptoms (62%), dyspareunia (57%), recurrent urinary tract infections (UTIs) (29%), vaginal extrusion (20%) and erosion involving the urinary tract (5%). Patients had a mean of 2 prior anti-incontinence procedures (range 2-3). Over two-thirds had a combination of retropubic and transobturator MUS. Mean number of pre-operative investigations was 3.5 (1-6) including voiding cystourethrogram, cystoscopy and urodynamics. Two patients had complete remission, 14 partial remission, and five failed. Mean postoperative total UDI-6 and IIQ-7 scores at last clinic visit were 10 (range: 0-16/SD 4.1) and 11 (range: 0-28/SD 10.3), respectively.

CONCLUSION

The management of women with suboptimal outcomes following two synthetic MUS from transvaginal excision results in modest symptomatic improvement but low permanent complete remission and frequent need for additional therapies.

Suprameatal urethrolysis with Martius flap for refractory bladder outflow obstruction following stress incontinence surgery in females

AIMS

To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO).

METHODS

A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence.

RESULTS

Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P < 0.01). Among the seven patients who required catheterization preoperatively, five patients (71%) recovered volitional voiding. Two patients (18%) continued to require indwelling or intermittent catheterization and underwent additional surgery for BOO. SUI recurred in one patient (9%). UUI persisted in all four patients who reported this preoperatively.

CONCLUSIONS

SMUM is successful in improving or relieving refractory BOO in this challenging patient population. After TVU, we believe that Martius flap interposition is critical to preventing recurrent fixation of the urethra to the pubic bones and thus achieving improved voiding.

Quality of life and objective outcome assessment in women with tape division after surgery for stress urinary incontinence

BACKGROUND

Midurethral tapes may cause long-term complications such as voiding dysfunction, groin pain, de novo urgency or mesh erosion, which necessitate a reoperation. There is a paucity of data regarding health related quality of life in patients undergoing tape removal. The aim of the study was to evaluate quality of life (QoL) and objective outcome after midurethral tape division or excision.

METHODS

All patients who underwent a midurethral tape division for voiding difficulties, pain or therapy resistant de novo overactive bladder between 1999 and 2014 were invited for follow-up. A control group with a suburethral tape without division was established in a 1:2 ratio and matched for age, tape used and year of tape insertion. Patients completed the Kings´ Health Questionnaire (KHQ), Incontinence Outcome Questionnaire, Female Sexual Function Index Questionnaire and the Patient Global Impression of Improvement score.

RESULTS

Tape division or excision was performed in 32 women. Overall, 15 (60%) of 25 women who were alive were available for clinical examination and completed the questionnaires. Tape division was performed for voiding dysfunction (n = 7), overactive bladder (n = 2), mesh extrusion (n = 3) and ongoing pain (n = 3). Median time to tape division/excision was 10 months. Three women in the tape division group had undergone reoperation for stress urinary incontinence (SUI). At a median follow-up of 11 years (IQR 9-13) subjective SUI rate was 53% (8/15 women) in the tape division group and 17% (5/30) in the control group (p = 0.016), with no significant differences in objective SUI rates between groups. With regard to quality of life, the study group had significantly worse scores in the SUI related domains role limitation, physical limitation, severity measures and social limitations (KHQ) compared to the control group.

CONCLUSIONS

Women needing tape division or excision have lower SUI related QoL scores compared to controls mostly because of higher subjective SUI rates.

The Outcome of Repeated Mid Urethral Sling in SUI Treatment after Vaginal Excisions of Primary Failed Sling: Preliminary Study

Mid urethral sling is the standard in SUI treatment. Nevertheless, the risk of reoperation reaches 9%. There is no consensus as to the best treatment option for complications. A question is raised: what is the optimal way to achieve the best result in patients after primary failure? The aim of the study was to evaluate the outcomes of repeat MUS surgery in patients after excision of the sling with recurrent SUI. We compared its effectiveness with uncomplicated cases treated with TVT. 27 patients who underwent the repeated MUS and 50 consecutive patients after primary TVT were enrolled in the study. After 6 months, we have found that 24 (88.46%) patients from repeat sling group and 48 (96%) patients after primary sling were dry (1-hour pad test, 2 g or less). The difference between groups was not significant. We showed statistically significant improvement of quality of life in both groups. In conclusion, we showed that repeated sling after MUS excision is almost as effective as primary MUS. We postulate that sling excision and repeated MUS may be the best option for persistent SUI and/or complications after MUS procedures. Further multicenter observations are ongoing as to provide results on bigger group of cases.