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

Can pelvic floor muscle function before surgery determine the outcome of surgical treatment of stress urinary incontinence in women?

AIM

The study aimed to determine whether pelvic floor muscle (PFM) function before surgery may correlate with the success of surgical interventions for treating stress urinary incontinence (SUI). Our hypothesis was that addressing identified variables in preoperative rehabilitation could potentially improve surgical outcomes.

METHODS

This prospective observational study was conducted at a single center and enrolled women qualified to mid-urethral tape insertion for SUI between 2020 and 2022. Digital palpation and manometry (Peritron™ 9300 V) were used to evaluate PFM function. The following parameters were acquired: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), the area under the curve during a 10-second MVC, moreover the ability to perform correct PFM contraction, reflexive PFM contraction during cough and relaxation were assessed. All measurements were performed before the surgical treatment and during follow-up assessments at 1, 3, and 6 months postoperatively. The primary endpoint of the study was defined as objective cure, characterized by a negative cough stress test (CST), along with a subjective assessment based on the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7).

RESULTS

The study involved 57 eligible female participants, all of whom completed the 6-month follow-up. Objective cure was observed in 75.44% of cases, while subjective cure was reported in 33%. There was no association between PFM parameters and surgical outcomes.

CONCLUSION

The success of surgical treatment of SUI 6 months postsurgery is not related to preoperative pelvic floor muscle function.

Unilateral J-cut division versus partial and subtotal removal techniques in female patients with mesh-related urethral obstruction: Multicentric comparative study

Objective

To compare the functional (obstruction relieving) outcomes and complications of unilateral J-cut division, partial and subtotal vaginal removal techniques were performed for mesh-related urethral obstruction (MRUO) in females.

Methods

Patient review included demographics, a medical history and proforma with details of lower urinary tract symptoms (LUTS), physical and urodynamic findings, detailed surgical reports and follow-up data. Variables were compared between the three groups.

Results

Out of 130 patients with sling revision surgery (SRS), 54 women underwent SRS for MRUO with a median follow-up of 48 (17-96) months. Unilateral J-cut division, partial and subtotal vaginal removal techniques were performed in 12, 31 and 11 patients with a median duration of surgery of 30 (25-34), 40 (35-56) and 60 (60-70) minutes, respectively (p = 0.001). Statistically significant increase in median maximum free urine flow rate and decrease in median post-void residual urine volume were found after SRS in the three groups, while de novo stress urinary incontinence (SUI) developed in 10%, 44% and 60% of the patients in the unilateral J-cut division, partial and subtotal removal groups, respectively (p = 0.007).

Conclusions

The unilateral J-cut division technique was as effective as the partial and subtotal vaginal removal techniques in relieving MRUO with a shorter duration of surgery time (p = 0.001) and lower risk of de novo SUI (p = 0.007). Comparative studies with a larger number of patients are needed.

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.

Comparison of early loosening vs delayed section of mid-urethral slings for postoperative voiding dysfunction

INTRODUCTION AND HYPOTHESIS

Bladder outlet obstruction (BOO) is a common occurrence after midurethral sling (MUS) insertion and can result in acute or chronic urinary retention or de novo lower urinary tract symptoms (LUTS). However, the management of BOO after MUS is not standardised. The objective of this study was to compare two therapeutic strategies for suspected BOO after MUS.

METHODS

Patients who had surgical revision for voiding dysfunction with a post-void residual (PVR) ≥100 ml after MUS in five centres between 2005 and 2020 were included in a retrospective study. Patients were divided into two groups: early sling loosening (EL) vs delayed section/excision of the sling (DS).

RESULTS

Seventy patients were included: 38 in the EL group and 32 in the DS group. The postoperative complication rate was comparable in both groups (10.5% vs 12.5%; p = 0.99). At 3 months, the rate of withdrawal from self-catheterisation was similar in the two groups (92.1% vs 100%; p = 0.25) as was the PVR (57.5 vs 63.5 ml; p = 0.09). After a median follow-up of 9 months, there were significantly more patients with resolved voiding dysfunction in the EL group (63.2% vs 31.3%; p = 0.01). The rate of persistent/recurrent stress urinary incontinence (SUI) was higher in the DS group (21% vs 43.7%; p = 0.04). In multivariate analysis, the main predictive factor of recurrent SUI was DS (OR 2.87, 95% CI 1.01-8.60, p = 0.048).

CONCLUSIONS

Early loosening of MUS in the case of postoperative voiding dysfunction offers better efficacy than DS of the sling, with a lower risk of recurrent/persistent SUI.

Cost-effectiveness Analysis: Autologous Rectus Fascial Sling Versus Retropubic Midurethral Sling for Female Stress Urinary Incontinence

IMPORTANCE

There are limited data on the economic comparison between retropubic midurethral sling and autologous fascial sling.

OBJECTIVE

This study aims to evaluate the cost-effectiveness of autologous rectus fascial sling compared with retropubic midurethral sling from both hospital and health care perspectives.

STUDY DESIGN

A decision tree model was developed with 1 year of follow-up. We included variables such as objective success rate, complications and subsequent treatments, and retreatment for incontinence. The model included the index procedure and 1 retreatment for stress urinary incontinence. Cost estimates were calculated from both hospital and health care perspectives. The outcomes were expressed in incremental cost-effectiveness ratio (ICER) or cost per quality-adjusted life-year (QALY). An ICER <$50,000/QALY was considered cost-effective.

RESULTS

From a hospital perspective, the overall cost of retropubic midurethral sling was higher than autologous rectus fascial sling ($2,348.94 vs $2,114.06), but was more effective (0.82 vs 0.80 QALYs). The ICER was $17,452/QALY. From a health care perspective, the overall cost of autologous rectus fascial sling was higher than retropubic midurethral sling ($4,656.63 vs $4,630.47) and was less effective. Retropubic midurethral sling was the dominant strategy, with ICER of -$1,943.32/QALY. If the success rate of autologous rectus fascial sling was ≥84.39%, or the cost of retropubic midurethral sling surgery was > $2,654.36, then autologous rectus fascial sling would become cost-effective.

CONCLUSIONS

Retropubic midurethral sling is the cost-effective treatment from the hospital perspective and the dominant treatment from the health care perspective. However, changes in the costs and success rates of surgical procedures can alter the cost-effectiveness results.

Cost-Effectiveness of Prophylactic Retropubic Sling at the time of Vaginal Prolapse Surgery

BACKGROUND

Prophylactic midurethral sling (MUS) at the time of prolapse repair significantly reduces risk of de novo stress urinary incontinence (SUI), but it is associated with some small but significant morbidities. Since there has not been a standardized approach to MUS utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying MUS strategies in addressing risk of de novo SUI.

OBJECTIVES

We aimed to compare the cost-effectiveness of the three MUS utilization strategies in treating de novo SUI one year following vaginal prolapse repair. The three approaches are: 1) staged strategy: prolapse repair without prophylactic MUS, 2) universal sling: prolapse repair with prophylactic MUS, and 3) selective sling: prolapse repair with prophylactic MUS only in patients with a positive prolapse-reduced cough stress test (CST).

STUDY DESIGN

We created a decision analysis model to compare staged strategy, universal sling, and selective sling. We modeled probabilities of de novo SUI, patients choosing subsequent MUS surgery for de novo SUI, and outcomes related to MUS. De novo SUI rates were determined for each strategy from published data. Likelihood of patients with de novo SUI choosing MUS surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic MUS at their index prolapse repair. Finally, outcomes related to MUS including recurrent or persistent SUI, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications were all derived from publicly available data. All MUS was assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or previous literature converted to 2020 US dollars with the Consumer Price Index. The primary outcome was modeled as the incremental cost effectiveness ratio (ICER). We performed multiple one-way sensitivity analyses to assess model robustness.

RESULTS

The lowest cost strategy was the staged strategy which costs $1,051.70 per patient, followed by $1,093.75 for selective sling and $1,125.54 for universal sling. The selective sling approach, however, had the highest health utility value; therefore, universal sling was dominated by selective sling as it is both less costly and more effective. When compared to the staged strategy, selective sling was cost-effective with ICER of $2,664/QALY, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent MUS surgery for de novo SUI after index surgery. Only when this proportion exceeded 62% did universal sling become the cost-effective option as selective sling surpassed the predetermined ICER threshold and became dominated.

CONCLUSION

Selective sling was the preferred and cost-effective strategy in treating de novo SUI one year following vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo SUI after prolapse repair as well as the benefits and risks of prophylactic MUS.

Cost-effectiveness Analysis of Early Sling Loosening Versus Delayed Sling Lysis in the Management of Voiding Dysfunction After Midurethral Sling Placement

OBJECTIVE

The aim of this study was to perform a cost-effectiveness analysis comparing the management for ongoing voiding dysfunction after midurethral sling placement, including early sling loosening and delayed sling lysis.

METHODS

A Markov model was created to compare the cost-effectiveness of early sling loosening (2 weeks) versus delayed sling lysis (6 weeks) for the management of persisting voiding dysfunction/retention after midurethral sling placement. A literature review provided rates of resolution of voiding dysfunction with conservative management, complications, recurrent stress urinary incontinence, or ongoing retention, as well as quality-adjusted life years (QALYs). Costs were based on 2020 Medicare reimbursement rates. Incremental cost-effectiveness ratios were compared using a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed.

RESULTS

At 1 year, early sling loosening resulted in increased costs ($3,575 vs $1,836) and higher QALYs (0.948 vs 0.925) compared with delayed sling lysis. This translated to early sling loosening being the most cost-effective strategy, with an incremental cost-effectiveness ratio of $74,382/QALY. The model was sensitive to multiple variables on our 1-way sensitivity analysis. For example, delayed sling lysis became cost-effective if the rate of voiding dysfunction resolution with conservative management was greater than or equal to 57% or recurrent stress urinary incontinence after early loosening was greater than or equal to 9.6%. At a willingness-to-pay threshold of 100,000/QALY, early sling loosening was cost-effective in 82% of microsimulations in probabilistic sensitivity analysis.

CONCLUSIONS

Early sling loosening represents a more cost-effective management method in resolving ongoing voiding dysfunction after sling placement. These findings may favor early clinical management in patients with voiding dysfunction after midurethral sling placement.

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.

Complications of synthetic mesh inserted for stress urinary incontinence

OBJECTIVE

To provide an update on the literature regarding the management of complications secondary to synthetic mesh placed to treat stress urinary incontinence (SUI).

METHODS

We performed a systematic review of the literature using a multi-database structured search within OVID, the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE) and Cochrane library databases; using the keywords: urology, incontinence, mesh and surgery.

RESULTS

Several million synthetic polypropylene meshes have been inserted into women worldwide to manage SUI. Unfortunately, a significant number of women have now reported life-changing complications. We found a paucity of studies, heterogeneity of cohorts, poor long-term follow-up, and lack of evidence on the effective management of mesh-related complications.

CONCLUSIONS

The contemporary evidence is low-level and often contradictory, which prevents robust recommendations regarding treatment. A prospective registry will be required to generate meaningful outcome data and help in the complex management of patients who have mesh-related complications.

Delayed presentation of mons pubis abscess formation following MUS-case report and surgical video

INTRODUCTION AND HYPOTHESIS

Mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) has relatively low complication rates. However, although rare, complications such as bladder wall, prepubic and thigh abscess occur. We present an unusual case of MUS vaginal mesh exposure followed by mons pubis abscess formation occurring 18 years postoperatively because of inadvertent prepubic insertion of the right arm. Our objectives were to raise awareness about such a rare complication and to describe the approach for sling removal.

METHODS

A 75-year-old woman presented with gradual swelling on the mons pubis followed by pain with a past history of MUS insertion. Examination revealed a palpable, tender, non-fluctuant mass, extending about 10-15 cm from mons pubis to the right labia. There was a 2 × 2-cm vaginal mesh exposure. Following imaging, an examination under anaesthesia was performed with vaginal exploration and complete removal of the right arm of the MUS and closure of the vagina.

RESULTS

Six months postoperatively, all surgical sites had healed well, and there was no recurrent SUI or persistent mesh exposure.

CONCLUSIONS

Unusual long-term complications of MUS should be considered and recognized. Thorough evaluation is crucial for informed decision-making related to treatment strategies. The vaginal approach to mesh removal is safe and should be practised by experienced surgeons. Patients should be informed regarding the possibility of incontinence after sling removal.

[Surgical management of suburethral sling complications and functional outcomes]

OBJECTIVES

To identify various clinical presentation leading to the diagnosis of mid-urethral sling (MUS) complications and to analyze the functional outcomes after surgical management of these complications.

METHOD

Retrospective observational monocentric study of all patients treated by MUS section or removal, between December 2005 and October 2019, in a pelviperineology centre.

RESULTS

During this study, 96 patients were included. MUS complications surgically managed were vaginal mesh exposure (48 %), urethral mesh exposure (17 %), bladder mesh exposure (10 %); dysuria (30 %), pain (6 %), and infection (3 %). The mean time to diagnosis was 2 years. This diagnosis delay was caused by a non-specific and heterogeneous symptomatology. Surgical management consisted in MUS partial removal (79 %) and MUS simple section (21 %) with low perioperative morbidity. At three months follow-up, 36 patients (53 %) had stress urinary incontinence (SUI), including 13 (19 %) de novo (meaning no SUI before MUS section/removal) and 19 (28 %) had overactive bladder, including 9 (13 %) de novo. Half of the patients with SUI after MUS section/removal were able to be treated by a second MUS with a success rate of 83 % at 3 years.

CONCLUSION

Clinical presentation of MUS complications is heterogeneous. Surgical treatment was associated with low morbidity in our study. Post-operatively, half of the patients had SUI and a second MUS was a relevant treatment option after proper evaluation.

LEVEL OF EVIDENCE

4.

Mesh complications: best practice in diagnosis and treatment

Mesh was a promising, minimally invasive, and 'gold standard' treatment for urinary stress incontinence. Time has shown that complications from these devices can happen early, or even several years, after mesh placement and can be catastrophic. Pain, erosion, voiding dysfunction, infection, recurrent UTIs [urinary tract infections (UTIs)], fistulae, organ perforation, bleeding, vaginal scarring, neuromuscular alterations, LUTS (lower urinary tract symptoms), bowel complications and even immune disorders have been linked to mesh. Various tools, such as imaging, endoscopic and functional studies, are available for diagnosis of mesh complications. Since the spectrum of complications is wide, involvement of other specialties is usually beneficial in the diagnosis and management of these complications. There is still much to learn on the accuracy and utility of diagnostic studies in each type of complication. Evidence on the best diagnostic and treatment pathways for these complications is scarce but continuously growing as information is being reported, and we continue to gain expertise in dealing with patients affected by mesh. Treatment options include conservative and medical management initially and then open or minimally invasive surgical procedure approaches. This article will describe diagnostic and treatment pathways for mesh complications.

Management of post-midurethral sling voiding dysfunction. International Urogynecological Association research and development committee opinion

Voiding dysfunction following midurethral sling procedures is not a rare event. There is no current consensus regarding management of this complication. Although it is often transient and self-limiting, chronic post-midurethral sling voiding dysfunction may lead to irreversible changes affecting detrusor function. Initial management includes intermittent catheterization, and addressing circumstantial factors interfering with normal voiding, such as pain. Early sling mobilization often resolves the dysfunction, and is associated with minimal morbidity. Sling incision or excision at a later stage, although fairly effective, could be associated with recurrence of stress urinary incontinence. There is insufficient evidence to justify urethral dilatation in this context.