Counselling and treatment for synthetic mid-urethral slings.

Abstract

Female stress urinary incontinence (SUI) is a condition that affects women worldwide. While treatment options span behavioural therapy, pelvic floor physical therapy, continent devices, and surgery, many patients turn to surgical options owing to their longevity and efficacy. The modern midurethral sling (MUS) with synthetic mesh was popularized in the 1990s and has become the gold standard for surgical treatment for SUI since then. In their 2017 Cochrane review, Ford et al. concluded that MUS has a good safety profile and is highly effective. While there are multiple studies looking at efficacy of these slings, the urogynaecological world finds itself at a crossroads (once again) as popular culture has targeted mesh safety (once again) for midurethral surgeries. This past year, American media including 60 Minutes, the New York Times, and a Netflix documentary have reported on both the purported safety concerns of synthetic mesh and profiteers luring women into unnecessary surgical excision of these implants. Because of this, many of our patients have requested biologic and autologous options for their MUS procedures. However, the differences in efficacy and invasiveness between these treatment options and synthetic mesh are dramatic, leaving many surgeons in a difficult predicament regarding an elective surgical procedure. While midurethral slings are a gold standard for treatment, they should not be a one-size-fits-all treatment. What the gynaecologic community needs is more research (i) demonstrating the risk factors for sling complications, which would allow providers to appropriately select ideal patients for these procedures, and (ii) to publicise these results both in the scientific literature and through the media, which have vilified the use of these products. In their article, Clancy et al. bring relevant data that both reinforce the safety of MUS – revision rates were found to be 2.4% in their cohort – but also highlight important preoperative considerations providers should note. Active smoking status, previous hysterectomy, and concomitant prolapse surgery at time of MUS were all found to be independently associated with increased risk for MUS revision/removal. This adds to Unger's case-control study (Unger et al., Int Urogynecol J 2016;27:117–22) also looking at risk factors of MUS revision, which noted concurrent apical repair as a risk factor for revision and that overall revision rates were low (2.7%). Clinicians can use the information from the research of Clancy et al. and Unger et al. when counselling patients about synthetic mesh MUS, risks of mesh complications, and alternative options. We can confidently cite the low revision rates and tailor our treatment for higher risk patients by prescribing vaginal estrogen pre- or post-operatively, or possible staging procedures. As patient advocates and mentors, we need to demonstrate whether the slings we utilize so commonly are indeed safe through more trials such as these, and then publicize these results widely before one of our best and safest treatment options is stripped from us. None declared. Completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.