Challenges of Multidimensional Outcome Reporting after Suburethral Mid Urethral Sling Removal

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review

OBJECTIVE

To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications.

DATA SOURCES

A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal.

METHODS OF STUDY SELECTION

All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible.

TABULATION, INTEGRATION, AND RESULTS

We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent.

CONCLUSION

Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD 42018093099.

Mesh Sling Arm Removal for Persistent Pain After an Initial Vaginal Suburethral Mesh Sling Removal Procedure

OBJECTIVES

Pain is a recognized complication of mid-urethral slings (MUS), which may lead to suburethral sling removal (SSR) alone, or to a more extensive removal approach. We report on the outcomes of women who required an SSR or an additional secondary MUS arm removal for pain only.

METHODS

After Institutional Review Board (IRB) approval, the charts of nonneurogenic women who underwent SSR for pain only were reviewed. Demographic information, MUS type, self-reported pain resolution, and preoperative and postoperative questionnaires, including Urogenital Distress Inventory-Short form question 6 (UDI-6 Q6) scores, were collected for the SSR (group 1) and secondary removal (group 2) groups.

RESULTS

Of 52 women who underwent SSR for pain only between 2005 and 2018, 16 (31%) required a secondary procedure to remove the extension arms due to persistent pain after SSR. All women in group 2 experienced pain immediately after SSR (UDI-6 Q6 score of 2 to 3). Patients whose pain improved after SSR presented at a median 61 months after MUS whereas those in group 2 underwent SSR at median 34 months after MUS. Median duration of follow-up in group 2, after the secondary procedure, was 34 months. Over one half of those in group 2 (54%) noticed pain cure/improvement. Seven were left with persistent pain.

CONCLUSIONS

In women who underwent SSR for pain only, 67% reported pain resolution. An additional procedure to remove the extension arms of the mesh was performed in one third of women for persistent pain after SSR.

Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS)

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

Multidimensional outcomes of suburethral synthetic midurethral sling removal

PURPOSE

To report multidimensional outcomes encompassing pain, dyspareunia, and recurrent urinary tract infections (UTIs), following suburethral sling removal (SSR) of synthetic midurethral slings (MUS) placed for female stress urinary incontinence.

METHODS

We reviewed a prospectively maintained, IRB-approved database of women undergoing SSR at our institution. Demographic data, type of sling, and symptoms along with Urogenital Distress Inventory-Short Form (UDI-6) scores both before and after SSR were analyzed. Success was defined using several modalities including patient-reported symptoms (ideal outcome) and UDI-6 questionnaire.

RESULTS

From 3/2006-2/2017, 443 women underwent SSR of which 230 met study criteria with median overall follow-up of 23 months (mean 30 months). 180/230 (78%) patients reported 3 or more symptoms at presentation. Median most recent post-SSR total UDI-6 score was 38 vs. 50 at baseline (p < 0.0001). By UDI-6, 53% of patients achieved success post-SSR. An ideal outcome was attained in 22/230 (10%) patients. A modified outcome allowing for one minimally invasive anti-incontinence procedure and excluding sexual activity classified 112/230 (49%) patients as successes.

CONCLUSIONS

While patients with MUS present with multiple symptoms, following SSR, there is sustained improvement in multiple symptom domains, including pain and urinary incontinence. Allowing for minimally invasive anti-incontinence procedures (not inclusive of subsequent suburethral sling), the rate of success was 49%, which was comparable to that derived from UDI-6 scores (53%).