Quality of life outcomes after transobturator tape full removal surgeries: A monocentric experience

Objective

The objective of this study is to describe a standardised technique of full TOT removal with groin dissection and to report clinical improvement, satisfaction, safety and long-term functional, quality of life (QoL) and sexual QoL outcomes.

Materials and methods

A retrospective review enrolling all women who had full TOT removal, in a tertiary referral centre from May 2017 to November 2020. Functional outcomes, satisfaction and QoL were assessed using a bespoke composite questionnaire (UDI-6, EQ-5D-5L and ICIQ-S) with additional questions on sexual QoL. Secondary outcomes were post-operative recurrent stress urinary incontinence (SUI) and complication rate according to the Clavien-Dindo classification.

Results

Full TOT removal using a vaginal approach and bilateral groin/para-labial incisions was performed in 67 patients. Chronic pelvic pain was the main indication for mesh removal (51% of cases, n = 34). QoL questionnaires were answered by 43 patients. The satisfaction rate was high 86% (n = 37), and 81% (n = 35) of the patients considered the surgery successful. Seventy per cent (n = 30) of patients returned to having a sexual life after surgery. Recurrent SUI was reported in 32% (n = 14) of cases. The complication rate was 10% (7/67), all of them Clavien-Dindo ≤2.

Conclusion

Despite a high rate of postoperative bothersome SUI, full TOT removal with bilateral groin dissection improves pain and QoL. It is associated with a high overall satisfaction rate and an acceptable rate of complications.

The Potential of Non-ablative Erbium (YAG) Laser Treatment for Complications After Midurethral Sling Surgery: A Narrative Review

Midurethral sling (MUS) surgery, using tension-free vaginal tape and transobturator tape, has been widely adopted for the treatment of stress urinary incontinence (SUI). However, postoperative complications, including persistent urinary incontinence, mesh exposure, and pain, have become problematic, and surgical treatments for these complications face challenges, such as invasiveness, treatment-resistant cases, and recurrence. This review provides an overview of the current evidence regarding these complications and the potential of vaginal non-ablative erbium (YAG) laser (VEL) treatment as a minimally invasive option with low risk of complications. Studies have suggested the effectiveness of VEL treatment, performed using devices such as IncontiLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), for persistent urinary incontinence after MUS surgery, pain following mesh removal, and asymptomatic mesh exposure. VEL treatment is expected to be a new treatment option for complications following MUS surgery; however, further large-scale comparative trials are required to verify its efficacy and safety and to establish criteria for its indications. Appropriate assessment of the indications and provision of sufficient information to patients is important when presenting VEL as a treatment option.

Total trans-obturator tape (TOT) removal; a case series including pain and urinary continence outcomes

Introduction and hypothesis

For many years, mid-urethral mesh tape (MUT) was the gold-standard procedure for management of stress urinary incontinence (SUI). However, significant concerns were raised over its safety. We present a case series of total trans-obturator tape (TOT) removals, performed in a tertiary unit over a 3-year period. We aim to evaluate improvement of pain and change in urinary continence symptoms following mesh explantation.

Methods

This is a retrospective case series of the outcomes of total TOT removal. Primary outcome is the change in pain scores following total removal, assessed preoperatively, at discharge and follow-up. Secondary outcomes were perioperative complications, including return to theatre, re-admission rates and incidence of worsening SUI and overactive bladder symptoms (OAB) postoperatively. Statistical analyses were performed using SPSS 27.0 package (IBM, Chicago, IL) and the GraphPad Prism 9 statistical packages.

Results

Nineteen women were identified. Mean age was 52 years and mean BMI was 31. Indications for mesh removal were: chronic pain (95%), vaginal exposure (37%) and pelvic sepsis (5%). No patients had return to theatre. Median intraoperative blood loss was 200 ml (interquartile range [IQR]: 150–288). Mean length of mesh excised was 22 cm. Mean postoperative hospital stay was 2 days. At follow-up, most patients (72%) reported “improvement” of their mesh-related pain at follow-up, while 6% reported “worsening” of pain. Eighty-three per cent of patients reported worsening SUI, and 50% reported worsening OAB symptoms.

Conclusions

In the absence of sepsis, significant intraoperative complications are rare during total TOT removals. While 72% of patients reported improvement of their mesh-related pain, 6% still reported worsening pain after total mesh excision.

Predictors of prolonged hospitalization and perioperative complications following mid-urethral sling mesh removal

PURPOSE

To assess preoperative and perioperative characteristics associated with increased length of stay and major complications after mid-urethral sling mesh removal.

METHODS

We performed an IRB-approved retrospective analysis of patients who underwent mid-urethral sling mesh removal. Demographic data and baseline surgical characteristics were collected. Operative reports and hospital/clinic notes were reviewed for complications which were categorized using the Clavien-Dindo Classification scheme. Length of stay was deemed abnormal if greater than 1 day. Complications were assessed using multivariate regression analysis.

RESULTS

A total of 468 patients were identified as having undergone mid-urethral sling mesh removal. Mean age was 56 (± 11.1). 431 patients had either retropubic or transobturator slings. 241 patients underwent retropubic or groin exploration as a part of their mesh removal. A prolonged length of stay was noted in 73 patients (15.6%) and 13 patients (2.8%) experienced a Clavien Grade 3 complication. Pre-operative narcotic/benzodiazepine use, concomitant surgical procedure, bladder injury, increased ASA class, and major complications had an increased odds of a prolonged length of stay. Patients who experienced a bladder injury, groin/suprapubic incision, and estimated blood loss of over 400 mL had an increased odds of Clavien Grade 3 complications.

CONCLUSIONS

Patient characteristics and perioperative factors are associated with increased length of stay and major complications after mid-urethral sling mesh removal.

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%).

Management of complications arising from the use of mesh for stress urinary incontinence-International Urogynecology Association Research and Development Committee opinion

INTRODUCTION AND HYPOTHESIS

Management of pain or mesh exposure complications after stress incontinence surgery has become a new issue over the last 20 years with the introduction of mesh techniques to treat stress incontinence. There is much debate regarding the incidence of complications and how best to treat them.

METHODS

A working subcommittee from the International Urogynecology Association (IUGA) Research and Development (R&D) Committee was formed. An initial document was drafted based on a literature review. The review focused on complications of vaginal mesh inserted for stress incontinence. After evaluation by the entire IUGA R&D Committee revisions were made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee Opinion reviews the literature on the management of complications arising from the use of mesh for stress urinary incontinence. The review concentrated on the assessment and treatment of pain and exposure.

CONCLUSIONS

Complications after surgery for stress incontinence using mesh may not be common occurrences for individual surgeons. Complications may be difficult to manage and outcomes are variable. Specialist centres and a multidisciplinary approach may optimise treatment and reporting of outcomes.

Is pain relief after vaginal mesh and/or sling removal durable long term?

INTRODUCTION AND HYPOTHESIS

This study was to review our experience of pain relief durability in women who experienced initial pain resolution after vaginal mesh and/or sling removal (VMSR).

METHODS

A retrospective chart review of consecutive, nonneurogenic women who underwent VMSR for pain and reported persistent pain relief at the 6-month postoperative follow-up visit were assessed. Pre- and postoperative data collected were self-reported chief complaints, physical examination, other medical conditions associated with chronic pain, use of pain medications, Urogenital Distress Inventory-6 (in which question 6 specifically addresses pain), and the Numerical Pain Rating Scale (NPRS). Success was defined by continued resolution of pain assessed by score of 0 on NPRS (0 none to 10 terrible), (0-1 on the Urogenital Distress Inventory-6 (UDI-6) question 6, subjective report of pain-free status, and/or no chronic use of pain medications other than those prescribed for non-mesh-related pain.

RESULTS

Between 2006 and 2015, 125 of 356 women met study criteria. Mean follow-up after VMSR was 3.5 (range 0.5-10) years. Among 25 women who did not meet success criteria by questionnaire answers or subjective report, 21 had causes unrelated to their original mesh/sling placement and were pain free after they were addressed. Four women experienced delayed mesh-related pain return at 28, 46, 47, and 54 months, respectively; two required mesh removal surgery. Involvement in lawsuits and chronic pain-related medical conditions did not affect the durability of pain relief.

CONCLUSIONS

At a mean follow-up of 3.5 years, the original pain relief noted after VMSR was durably maintained.

Challenges of Multidimensional Outcome Reporting after Suburethral Mid Urethral Sling Removal

PURPOSE

We sought to determine the types and frequency of presenting symptoms in women undergoing suburethral mid urethral sling removal to improve outcome reporting after removal.

MATERIALS AND METHODS

Following institutional review board approval women who underwent suburethral mid urethral sling removal of 1 mid urethral sling were evaluated for their presenting symptoms and correlation with the UDI-6 (Urogenital Distress Inventory-Short Form) questionnaire. Demographic data were recorded. Patient reported presenting symptoms were categorized into 5 domains, including storage symptoms, voiding symptoms, pain, recurrent urinary tract infections or urinary incontinence. The UDI-6 was reviewed preoperatively and 6 to 12 months postoperatively. We also calculated an ideal outcome, defined as resolution of incontinence, pain, resumption of sexual activity and no need for further anti-incontinence procedures.

RESULTS

A total of 230 women from 2006 to 2017 met study inclusion criteria, including 116 who completed the UDI-6 postoperatively. Of the women 80% had 3 or more presenting symptoms with pain as the most common symptom. The most common combination of symptoms was all 5 domains, which was noted in 46 of the 230 women (20%). An increasing number of symptoms correlated with the total preoperative UDI-6 score. Symptom domains were associated with the corresponding UDI-6 subdomain questions. Domains not covered by the UDI-6, ie recurrent urinary tract infections and dyspareunia, accounted for 27% of reported symptoms. Due to limited data on sexual activity an ideal outcome was reached in 10% of patients but this rate was 40% after sexual activity information was excluded.

CONCLUSIONS

In this series the presenting symptoms were manifold in women undergoing suburethral mid urethral sling removal. The UDI-6 questionnaire correlated with many of these complaints. It may be used in outcome analysis in conjunction with self-reported symptoms.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

Management of complications of mesh surgery

PURPOSE OF REVIEW

Transvaginal placements of synthetic mid-urethral slings and vaginal meshes have largely superseded traditional tissue repairs in the current era because of presumed efficacy and ease of implant with device 'kits'. The use of synthetic material has generated novel complications including mesh extrusion, pelvic and vaginal pain and mesh contraction. In this review, our aim is to discuss the management, surgical techniques and outcomes associated with mesh removal.

RECENT FINDINGS

Recent publications have seen an increase in presentation of these mesh-related complications, and reports from multiple tertiary centers have suggested that not all patients benefit from surgical intervention.

SUMMARY

Although the true incidence of mesh complications is unknown, recent publications can serve to guide physicians and inform patients of the surgical outcomes from mesh-related complications. In addition, the literature highlights the growing need for a registry to account for a more accurate reporting of these events and to counsel patients on the risk and benefits before proceeding with mesh surgeries.

Prolapse Recurrence after Transvaginal Mesh Removal

PURPOSE

We determined the rate of pelvic organ prolapse recurrence after transvaginal mesh removal.

MATERIALS AND METHODS

Following institutional review board approval a longitudinally collected database of women undergoing transvaginal mesh removal for complications after transvaginal mesh placement with at least 1 year minimum followup was queried for pelvic organ prolapse recurrence. Recurrent prolapse was defined as greater than stage 1 on examination or the need for reoperation at the site of transvaginal mesh removal. Outcome measures were based on POP-Q (Pelvic Organ Prolapse Quantification System) at the last visit. Patients were grouped into 3 groups, including group 1--recurrent prolapse in the same compartment as transvaginal mesh removal, 2--persistent prolapse and 3--prolapse in a compartment different than transvaginal mesh removal.

RESULTS

Of 73 women 52 met study inclusion criteria from 2007 to 2013, including 73% who presented with multiple indications for transvaginal mesh removal. The mean interval between insertion and removal was 45 months (range 10 to 165). Overall mean followup after transvaginal mesh removal was 30 months (range 12 to 84). In group 1 (recurrent prolapse) the rate was 15% (6 of 40 patients). Four women underwent surgery for recurrent prolapse at a mean 7 of months (range 5 to 10). Two patients elected observation. The rate of persistent prolapse (group 2) was 23% (12 of 52 patients). Three women underwent prolapse reoperation at a mean of 10 months (range 8 to 12). In group 3 (de novo/different compartment prolapse) the rate was 6% (3 of 52 patients). One woman underwent surgical repair at 52 months.

CONCLUSIONS

At a mean 2.5-year followup 62% of patients (32 of 52) did not have recurrent or persistent prolapse after transvaginal mesh removal and 85% (44 of 52) did not undergo any further procedure for prolapse. Specifically for pelvic organ prolapse in the same compartment as transvaginal mesh removal 12% of patients had recurrence, of whom 8% underwent prolapse repair.