Sling Revision Research Articles

62: Complete midurethral sling removal: An analysis of mesh explantation by length

Mesh removal is an option for the management of complications arising from synthetic mesh placement for stress urinary incontinence (SUI). Definitions of “complete” versus “partial” removal of midurethral sling mesh vary. Using an objective measurement to define these terms could help physicians to better study mesh removal. To date, it has not yet been described how much mesh by length is explanted during complete retropubic (RP) and transobturator (TO) sling removals. The objective of this study was to determine the median length of midurethral slings, both RP and TO, that is explanted during complete removal of sling mesh. Following IRB approval, a retrospective chart review of a referral urogynecology practice was performed from January 2015 to December 2015 by CPT code 57287 (sling revision/removal). Complete removal of a RP sling was defined as excision of the vaginal portion as well as the retropubic arms coursing through the retropubic space, rectus abdominus, and subcutaneous tissues. Complete removal of a TO sling was defined as excision of the vaginal portion as well as the lateral arms coursing through the obturator/adductor muscles. Inclusion criteria included patients who had a prior RP or TO sling and underwent a complete sling removal with no prior history of sling excision. Single-incision slings and those with incomplete or unclear pathology reports were excluded. Mesh length in centimeters (cm) was collected and analyzed descriptively. A subanalysis was also performed comparing patient body mass index (BMI) by World Health Organization classification to explant length using a Mann-Whitney U test. Of the 114 patients undergoing complete sling removal, there were 55 sling explants included in the analysis. The median length of the complete RP mesh explants (n = 23) was 25.5 cm (15.4-35.2 cm). The median length of the complete TO mesh explants (n = 32) was 18.4 cm (12.8-29.2 cm). Patients with a normal BMI had a significantly smaller RP explant length (median = 23.3 cm) than obese patients (median = 29.0 cm), U = 13, p = 0.049. However, TO explant length was similar in patients with a normal BMI and those classified as obese (median: 18.2 cm vs 18.8 cm, respectively), U = 26, p = 0.98. This is the first series to describe the length of mesh explant based upon pathology after complete sling removal. Our study identified a wide range of mesh lengths in both RP and TO explantation. The lack of uniformity of sling length between patients complicates the preoperative prediction of an individual patient's suspected mesh length. Furthermore, for patients presenting with a history of sling revision, simply knowing the length of mesh previously excised does not provide the surgeon with enough information to estimate the amount of mesh remaining in vivo. Therefore, surgeons need to obtain both pathologic reports and detailed operative report description of previous mesh excisions to make an accurate prediction of the amount of mesh remaining in the patient. While our findings indicate a relationship between BMI and length of RP sling explanted, further study into other specific patient characteristics, which could affect mesh length, may be helpful.

Unplanned Hospital Visits in the First 30 Days After Urethral Sling Procedures

To evaluate unplanned hospital visits within 30 days of urethral sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. We accessed nonpublic data from the Office of Statewide Health Planning and Development in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (Current Procedural Terminology 57288) without concomitant surgery (other than cystoscopy) were included. Any subsequent emergency department visit, inpatient admission, or sling revision operation within 30 days of the original surgery were then examined. A total of 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure. Within 30 days, 1630 women (5.7%) had at least 1 unplanned hospital visit. This included 1327 emergency department visits (4.7%), 295 inpatient admissions (1.0%), and 79 sling revisions (0.28%). Urinary retention and Foley catheter problems were the most common emergency department visit diagnoses (18.7% of visits), followed by urinary tract infection (9.3% of visits). One in 18 women will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits (~81%). Our findings can be used to improve patient counseling and suggest areas that one might target to decrease unnecessary emergency department visits in the early postoperative period.

Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications

To determine if postoperative urinary retention and urinary tract infections (UTIs) were predictors of future mesh complications requiring surgical intervention after midurethral sling (MUS). Administrative data in Ontario, Canada, between 2002 and 2013 were used to identify all women who underwent a mesh-based MUS. The primary outcome was revision of the transvaginal mesh sling (including mesh removal/erosion/fistula, or urethrolysis). Two potential risk factors were analyzed: postoperative retention (within 30 days of procedure) and number of postoperative emergency room visits or hospital admissions for UTI symptoms. A total of 59,556 women had a MUS, of which 1598 (2.7%) required revision surgery. Of the 2025 women who presented to the emergency room or were admitted to hospital for postoperative retention, 212 (10.5%) required operative mesh revision. Of the 11,747 patients who had at least one postoperative UTI, 366 (3.1%) patients required operative mesh revision. In adjusted analysis, postoperative retention was significantly predictive of future reoperation (hazard ratio [HR] 3.46, 95% confidence interval [CI] 2.97-4.02), and this difference persisted when urethrolysis was excluded as a reason for sling revision (HR 3.08, 95% CI 2.62-3.63). Similarly, in adjusted analysis, each additional postoperative hospital visit for UTI symptoms increased the risk for surgical intervention for mesh complications (HR 1.74, 95% CI 1.61-1.87). Postoperative urinary retention and hospital presentation for UTI symptoms are associated with an increased risk of reoperation for MUS complications. These patients should be followed and investigated for mesh complications when appropriate.

Repeat Surgical Intervention for Stress Urinary Incontinence after a Failed Mid Urethral Sling

IntroductionWe determined the incidence of stress urinary incontinence surgery performed after mid urethral sling procedures and the impact of physician volume on mid urethral sling failure. MethodsAdministrative data were used to identify all women who underwent a mid urethral sling procedure in Ontario, Canada between 2002 and 2013. The primary outcome was subsequent stress urinary incontinence surgery. The primary exposure was surgeon mid urethral sling case volume with high volume defined as greater than the 75th percentile. ResultsA total of 59,556 women with a median age of 52 years (IQR 45–63) received a mid urethral sling, of whom 3.3% underwent additional stress urinary incontinence operations. The most common secondary surgery was a repeat mid urethral sling in 78.3% of cases and a pubovaginal sling in 5.8%. The cumulative incidence of repeat stress urinary incontinence surgery at 10 years of followup was 5.2% (95% CI 4.9–5.5). On multivariable survival analysis the effect of surgeon mid urethral sling volume on subsequent stress urinary incontinence surgery was nonsignificant (HR 0.89, 95% CI 0.76–1.03). Younger patient age, lower comorbidity and simultaneous hysterectomy decreased the hazard of future stress urinary incontinence surgery. In this cohort 1,425 women (2.4%) required surgical revision or removal of the initial mid urethral sling, of whom 215 (15%) underwent a simultaneous or subsequent incontinence procedure. The most common procedure was still a mesh sling, which was placed in 159 women (74.0%). ConclusionsSecondary stress urinary incontinence surgery after mid urethral sling placement was observed in 3.3% of women. The majority of women with recurrent incontinence were treated with a repeat mid urethral sling. There is a nonsignificant trend toward higher mid urethral sling provider volume being correlated with a reduced risk of future stress urinary incontinence surgery.

Stress urinary incontinence surgery trends in academic female pelvic medicine and reconstructive surgery urology practice in the setting of the food and drug administration public health notifications.

To investigate the possible effects of the Food and Drug Administration (FDA) Public Health Notifications in 2008 and 2011 regarding surgical trends in transvaginal mesh (TVM) placement for stress urinary incontinence (SUI) and related mesh revision surgery in Female Pelvic Medicine & Reconstructive Surgery (FPMRS) practice in tertiary care academic medical centers in the United States. Surgical volume for procedures performed primarily by FPMRS surgeons at eight academic institutions across the US was collected using Current Procedural Terminology (CPT) codes for stress urinary incontinence repair and revision surgeries from 2007 to 2013. SAS statistical software was used to assess for trends in the data. There was a decrease in the use of synthetic mesh sling for the treatment of SUI at academic tertiary care centers over the past 7 years; however, this was not statistically significant. While the total number of surgical interventions for SUI remained stable, there was an increase in the utilization of autologous fascia pubovaginal slings (AFPVS). The number of mesh sling revision surgeries, including urethrolysis and removal or revision of slings, increased almost three-fold at these centers. These observed trends suggest a possible effect of the FDA Public Health Notifications regarding TVM on surgical practice for SUI in academic centers, even though they did not specifically warn against the use of synthetic mesh for this indication. Indications for surgery, complications, and outcomes were not evaluated during this retrospective study. However, such data may provide alternative insights into reasons for the observed trends. Neurourol. Urodynam. 36:1155-1160, 2017. © 2016 Wiley Periodicals, Inc.

Incontinence rates after midurethral sling revision for vaginal exposure or pain

Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure. We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency. This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence. In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P= .03) and long-term (7% vs 59%, P= .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P= .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively (P= .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal. In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.

Characterization of Lower Urinary Tract Symptoms Before and After Midurethral Sling Revision

Study ObjectiveTo characterize outcomes in women undergoing surgical revision of a midurethral sling and characterize factors associated with satisfaction of revision. DesignRetrospective cohort study (Canadian Task Force classification II-3). SettingA urogynecology clinic at a large academic referral center. PatientsWomen undergoing surgical revision of synthetic mesh midurethral sling (index surgery). InterventionsChart review was performed to obtain baseline clinicodemographic information, operative notes, urodynamic parameters, and symptom-specific distress and impact questionnaire data. Eligible women were then sent follow-up questionnaires that assessed reasons for index surgery, presence of dyspareunia, symptom-specific distress and impact, and satisfaction after mesh midurethral sling surgery. Measurements and Main ResultsOf 144 eligible women, 69 (47.9%) responded, 15 (10.4%) declined participation or were deceased, and 59 (41.6%) did not respond. The mean time from index surgery was 22.2 ± 14.0 months. Women with transobturator slings were more frequently revised for vaginal exposure (p = .003), whereas women with retropubic slings were more frequently revised for voiding dysfunction (p < .0001). Sixty-four percent of women were satisfied with surgery. Satisfied women had more improvement in pain (p = .04), dyspareunia (p < .001), and Patient Global Impression of Improvement questionnaire scores (p < .0001). Multivariable analysis showed that satisfaction decreased with increasing years in age (adjusted odds ratio = 0.95; 95% confidence interval, 0.90–0.99). ConclusionWomen who were satisfied with sling revision were younger and more likely to have resolution of pain and dyspareunia and improved Patient Global Impression of Improvement scores. This information may help to inform patients regarding expectations with regard to sling revision.

30-Day Morbidity and Reoperation Following Midurethral Sling: Analysis of 8772 Cases Using a National Prospective Database

To determine 30-day complications, risk of readmission, and reoperation for midurethral slings (MUS). The National Surgical Quality Improvement Program database from 2006 to 2013 was queried for MUS alone by excluding concurrent reconstructive, urologic, or gynecologic procedures. We assessed baseline characteristics, 30-day perioperative outcomes and 30-day readmission. Logistic regression analysis identified risk factors for the frequent complications. There were 8772 women who underwent MUS, of which 3830 (43.7%) and 4942 (56.3%) were performed by urologists and gynecologists, respectively. Patients of urologists were older, had higher frailty, and were more likely diabetic (all P < .05). Patients of gynecologists were more likely to have resident involvement compared to urologists (16.4% vs 11.2%, P < .001). Mean operative time was shorter for urologists compared to gynecologists (35.6 ± 29.2 minutes vs 38.1 ± 34.3 minutes, P < .001). The overall 30-day rate of any complication was 3.52%. Urinary tract infection (UTI) occurred in 2.2% vs 3.5% of the urologic and gynecologic patients, respectively (P=.001). After adjusting for frailty, body mass index, steroid use, age, operative time, and residency involvement, gynecologic performed surgery incurred an increased risk of UTI (OR 1.67, 95% CI 1.27-2.19; P=.001). Sixty-five (0.90%) patients were readmitted within 30 days, most commonly due to urinary symptoms. Sling revision for urinary obstruction occurred in 15 patients; 10 underwent repair of the bladder, urethra, or vagina. To our knowledge, we present the largest American cohort of MUS 30-day outcomes to date, stratified by specialty of performing surgeon. Overall, morbidity is low. UTI is the most common complication, and occurs at increased frequency for patients of gynecologists.

V2-01 TRANSVAGINAL SLING EXCISION: TIPS AND TRICKS

You have accessJournal of UrologyFemale Voiding Dysfunction1 Apr 2016V2-01 TRANSVAGINAL SLING EXCISION: TIPS AND TRICKS Marisa Clifton and Howard Goldman Marisa CliftonMarisa Clifton More articles by this author and Howard GoldmanHoward Goldman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2655AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Synthetic midurethral sling placement is the most common procedure performed for women with symptomatic stress urinary incontinence. Postoperative complications are well documented in the literature. The estimated rate of sling revision for urethral obstruction is approximately 2.3% and for mesh extrusion is 1.8%. However, this may be an underestimate of the true incidence. Herein, we present three separate cases of mesh excision and provide tips to improve surgical outcomes in these patients METHODS Three separate cases of mesh excision were recorded. Techniques utilized in sling excision were discussed in this video RESULTS Our first patient underwent transobturator sling in 2010 for symptomatic stress incontinence. Postoperatively, she developed voiding dysfunction and was evaluated for urinary hesitancy and weak stream. Her office cystoscopy was negative for mesh perforation and urodynamic study showed evidence of outlet obstruction. She elected to proceed with excision of a portion of the sling. Our second case is of a patient who underwent a sling for mixed urinary incontinence. Postoperatively, her urgency incontinence worsened significantly and she complained of significant dyspareunia. Her physical examination demonstrated pain where her sling was palpable at the midurethra. Cystoscopy was negative for mesh perforation, however, urodynamics showed evidence of bladder outlet obstruction. Our third patient underwent sling placement for stress incontinence in 2006. Approximately 2 months before presentation, her husband felt mesh during sexual intercourse. During physical examination, mesh was palpable at the right sulcus. The patient wished to have this portion of the sling removed. CONCLUSIONS In summary, plan incisions based on where mesh can be identified. If the location of the obstructing mesh is not apparent, use a cystoscope sheath or dilator to help with identification. If it is difficult to identify mesh during the dissection, a knife may help identify mesh from surrounding tissues. When performing sling excision for extrusion, ensure an adequate length of mesh is removed to prevent recurrence. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e180 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Marisa Clifton More articles by this author Howard Goldman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

18: Incontinence rates after midurtheral sling revision for vaginal exposure or pain

We describe the rate of postoperative urinary incontinence (UI) after midurethral sling (MUS) revision for the indication of vaginal mesh exposure and vaginal pain, as well as postoperative complaints of urgency and pain. This is an IRB approved retrospective cohort of patients who had undergone a vaginal synthetic mesh MUS sling revision at our institution from May 2004 to May 2014 for the indication of mesh exposure or pain. The preoperative indication for revision was collected as well as baseline characteristics including preoperative complaints of UI, pain and urgency. The type of sling revision was then separated into partial excision or complete excision. A partial removal of the sling was defined as removing only the portion of the sling that was exposed or causing pain. A complete removal of the sling was defined as both arms of the sling dissected out to bilateral pubic rami and then excised. Postoperative visits were reviewed for subjective complaints of UI, pain and urgency at short term (</= 16 weeks) and long term (>16 weeks) visits. The primary outcome of the study was recurrent rate of UI and the secondary outcomes were postoperative pain and urgency rates. Statistics were performed using Stata Statistical Software: Release 13. (StataCorp. 2013. College Station, TX). Ninety-four patients were identified to have undergone vaginal MUS removal for the indication of mesh exposure; 36 (38%) were partial and 58 (62%) were complete removal of the sling material. One hundred fifty-one patients were identified to have vaginal sling removal for the indication of pain; 25 (17%) had partial and 126 (83%) had complete removal of their sling. All patients had a short term follow up visit with a median follow up time of 5.9 weeks and 69% patients had a long term follow up visit with mean follow up time of 29 weeks. No difference was seen in preoperative complaints of UI, urgency or pain in either groups between the revision types performed. In the patients with the indication of mesh exposure with no preoperative complaint of UI, there is a significant increase in postoperative UI with complete excision versus partial excision of the sling at short term and long term follow up. In the patients with the indication of pain, a trend toward increase in newly reported postoperative UI with complete excision of the sling was seen at long term follow up, but this was not significant (Table 1). In the pain patients, 72% of partial excision and 76% of complete excision patients had resolution of their pain post operatively. No difference was seen in postoperative complaints of urgency or pain in either groups between the revision types performed. There is a difference in incontinence rates after partial and complete vaginal excision of MUS for the indication of mesh exposure and possibly for the indication of pain, with complete excision bearing the highest risk of postoperative incontinence in this cohort.

Urgency Incontinence before and after Revision of a Synthetic Mid Urethral Sling

We evaluate urgency urinary incontinence outcomes for patients who underwent revision of a presumed obstructing synthetic mid urethral sling and examine risk factors for persistent or de novo symptoms after surgery. From February 1, 2005 to June 1, 2013, 107 women underwent sling revision for new or worsening lower urinary tract symptoms after synthetic mid urethral sling surgery. Patients were grouped based on urgency urinary incontinence symptoms and characteristics associated with persistent or de novo symptoms after revision were examined using logistic regression models. Median followup was 29 months (IQR 12-54) and time to revision was 21 months (IQR 5-48). Patients presenting for sling revision with urgency incontinence (68) were more likely to experience a more than 6-month delay to revision vs those presenting with obstructive voiding symptoms (39) (OR 3.25, 95% CI 1.33-7.92, p <0.01). After revision urgency incontinence persisted in 76.5% (52 of 68) and was associated with a pre-revision need for anticholinergic medication (OR 5.58, 95% CI 1.44-21.39, p=0.01) and smoking (OR 5.21, 95% CI1.21-22.49, p=0.03). De novo urgency incontinence developed in 43.6% (17 of 39) of patients and was associated with de novo stress incontinence (OR 15.9, 95% CI 3.2-78.3, p <0.01). Women with post-revision urgency incontinence (denovo or persistent) had higher Urogenital Distress Inventory-6 scores than patients with no or resolution of urgency incontinence. Patients presenting with new or worsening urgency urinary incontinence after sling placement were more likely to undergo delayed revision compared to those presenting with obstructive voiding symptoms. There is a high rate of bothersome persistent and de novo urgency incontinence after sling revision. Patient expectations should be managed accordingly before sling revision.

Post-Prostatectomy Male Sling Revision and Early Results

IntroductionMale slings are an accepted form of therapy in the incontinent man with a reported 55% to 80% success rate. Failed slings may be salvaged by performing a retensioning surgical sling revision procedure. The procedure is performed through a perineal incision that partially exposes the cicatrix containing the sling. Imbricating sutures are then placed and the patient is discharged home the same day without a catheter. Operative and postoperative details of this procedure are presented. MethodsWe retrospectively analyzed the records of the first 16 patients to undergo sling revision from June 2010 to March 2013. Patient age, pad count before and after initial sling placement, sling revision and followup time were investigated. Operative time, complications and blood loss were also analyzed. ResultsMedian operative time was 37 minutes with a median blood loss of 5 ml. There were no surgical complications. The median daily pad count decreased from 4 to 1.3 (p = 0.002). After the procedure 63% of men improved and 44% were pad-free. ConclusionsSling revision appears promising as an easily reproducible salvage technique for failed slings.

Indications and risk factors for midurethral sling revision.

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement. This was a case-control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data. Of 3,307 women who underwent sling placement, 89 (2.7%, 95% CI 1.9 - 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8%), voiding dysfunction (42.7%), recurrent urinary tract infection (20.2%), mesh erosion (21.3%), vaginal pain/dyspareunia (7.9%), and groin pain (3.4%). The median time from the index to the revision surgery was 7.8 months (2.3 - 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95% CI 1.7 - 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95% CI 1.4 - 4.5). The rate of sling revision after midurethral sling placement was 2.7%. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

Retrospective Study on Outcomes after Midurethral Sling (MUS) Revision for Persistent Lower Urinary Tract Symptoms: What Can We Expect to Resolve?

Retrospective Study on Outcomes after Midurethral Sling (MUS) Revision for Persistent Lower Urinary Tract Symptoms: What Can We Expect to Resolve?

Indications and Risk Factors for Midurethral Sling Revision

Introduction and hypothesis To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement.

V1-14 REPAIR OF COMPLETE URETHRAL DISRUPTION DUE TO SYNTHETIC SLING COMPLICATION

You have accessJournal of UrologyFemale Pelvic Medicine & Reconstructive Surgery1 Apr 2014V1-14 REPAIR OF COMPLETE URETHRAL DISRUPTION DUE TO SYNTHETIC SLING COMPLICATION Nitya Abraham and Sandip Vasavada Nitya AbrahamNitya Abraham More articles by this author and Sandip VasavadaSandip Vasavada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.608AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral complications due to synthetic mid-urethral slings are rare. Possible causes may include unrecognized trocar injury, mesh implantation despite recognized injury, mesh contamination leading to inflammation and delayed perforation, and excessive sling tension. There is no consensus as to the surgical management of urethral complications with regard to how much mesh should be excised, whether an interposition flap should be utilized, and whether a pubovaginal sling should be placed at the time of surgery. We present a case of complete urethral disruption due to a synthetic mid-urethral sling complication. METHODS A 56 year old woman was referred for a hole in her urethra. She reported mixed urinary incontinence requiring 6 pads per day. She denied continuous incontinence, split stream, or recurrent UTI. Her surgical history was significant for prolapse repair and synthetic transobturator sling surgery complicated by synthetic sling extrusion with subsequent sling revision. Physical exam revealed complete urethral distraction distal to the bladder neck. The proximal urethral segment was about 2 cm in length and the distal urethral segment about 1 cm in length. The patient also had stage 3 pelvic organ prolapse. Cystoscopy confirmed that the urethral distraction was distal to the urethral sphincter. The bladder was normal. RESULTS The patient was counseled regarding surgical repair of the complete urethral distraction. A primary end-to-end urethral reconstruction was performed. Any residual synthetic mesh was excised. Given the good tissue quality and water-tight closure, we did not place an interposition flap. We also opted not to address her stress incontinence with concomitant fascial sling placement as we did not want to compromise the urethral repair. VCUG was performed after 3 weeks revealing no extravasation. The foley catheter was removed. On follow-up the patient reports bothersome urgency incontinence. She denies stress urinary incontinence. CONCLUSIONS Complete urethral disruption is a rare complication of synthetic mid-urethral sling surgery, that can be repaired primarily with good results. There is no consensus regarding the surgical management of such complications and thus an individualized approach should be used based on the patient’s presentation and surgeon expertise. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e295 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Nitya Abraham More articles by this author Sandip Vasavada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

563 TRANSLABIAL ULTRASOUND (TLUS) DETECTION IN URETHRAL MESH SLING REVISION: FACTORS ASSOCIATED WITH THE NEED FOR INTERPOSITIONAL TISSUE FLAP OR URETHRAL RECONSTRUCTION

You have accessJournal of UrologyUrodynmaics/Incontinence/Female Urology: Incontinence, Evaluation & Therapy (I)1 Apr 2013563 TRANSLABIAL ULTRASOUND (TLUS) DETECTION IN URETHRAL MESH SLING REVISION: FACTORS ASSOCIATED WITH THE NEED FOR INTERPOSITIONAL TISSUE FLAP OR URETHRAL RECONSTRUCTION Forrest Jellison, Leah Nakamura, Lisa Rogo-Gupta, Denise Chow, Chad Baxter, Ja-Hong Kim, Larissa Rodriguez, and Shlomo Raz Forrest JellisonForrest Jellison Los Angeles, CA More articles by this author , Leah NakamuraLeah Nakamura Los Angeles, CA More articles by this author , Lisa Rogo-GuptaLisa Rogo-Gupta Los Angeles, CA More articles by this author , Denise ChowDenise Chow Los Angeles, CA More articles by this author , Chad BaxterChad Baxter Los Angeles, CA More articles by this author , Ja-Hong KimJa-Hong Kim Los Angeles, CA More articles by this author , Larissa RodriguezLarissa Rodriguez Los Angeles, CA More articles by this author , and Shlomo RazShlomo Raz Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1959AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The objective of this study is to detect and localize urethral sling mesh by TLUS and to determine preoperative factors predictive of an interpostional tissue flap or urethral construction (UC). METHODS Patients who underwent excision of transvaginal mesh between 7/2005 to 7/2012 were retrospectively reviewed. Women that had only urethral mesh sling revision and pre-operative TLUS were included for analysis. Demographics, pre-operative, TLUS findings, and operative findings were compared. RESULTS A total of 43 (mean age 58 +/− 17, BMI 26 +/− 3.58, postmenopausal 32%) women underwent urethral mesh sling revision and pre-operative TLUS. UC or interpositional flap of tissue was performed in 44% (19) with a local flap (periurethral fascia, perivesical fat) in 68%, and a martius flap in 32%. TLUS was able to detect mesh in all patients. TLUS sensitivity and specificity was (74%, 100%) for reconstruction when mesh was within 1 mm of the lumen of bladder or urethra. TLUS findings of mesh within 1 mm of the urethral or bladder was predictive of urethral or bladder flap during reconstruction in 93% and was significant compared to those not requiring reconstruction, p<0.01. 63% (12) of patients requiring reconstruction were not identified on pre-operative cystoscopy of which 66% (8) were found to be within 1 mm of the urethra or the bladder lumen on ultrasound. TLUS findings of mesh folding or mesh location (proximal to distal) were not predictive of reconstruction. There was a higher rate of pre-operative stress and mixed incontinence (66% vs 48%, p=0.01) and subsequent surgical procedures for stress incontinence (63% vs 43%, p=0.03) in the reconstructive group. Significant risks for urethral reconstruction was age greater than 65 (p<0.01), BMI >25 (p<0.01), and parity > 3 (p.02).There was no significant difference in reconstruction operative times (105 +/− 25 vs 82 +/− 17, p=0.08), EBL (165 +/− 70 vs 177 +/− 171, p=74), or complications (5% vs 4%) compared to those who did not undergo reconstruction. CONCLUSIONS TLUS was able to detect and localize urethral sling mesh and may predict those who would need an interpositional flap or UC at the time of surgery. This technique may allow the surgeon to pre-operatively identify and council the patient about the need for reconstruction. This information needs to be applied prospectively to determine if indeed sling location within 1 mm of urethral lumen predicts need for UC or interpositional tissue flap. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e231 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Forrest Jellison Los Angeles, CA More articles by this author Leah Nakamura Los Angeles, CA More articles by this author Lisa Rogo-Gupta Los Angeles, CA More articles by this author Denise Chow Los Angeles, CA More articles by this author Chad Baxter Los Angeles, CA More articles by this author Ja-Hong Kim Los Angeles, CA More articles by this author Larissa Rodriguez Los Angeles, CA More articles by this author Shlomo Raz Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Economic Considerations for Mid-Urethral Sling Procedures Among Patients with Stress Urinary Incontinence

Stress urinary incontinence (SUI) is associated with a hefty economic burden. Retropubic and transobturator vaginal slings have become common surgical options for women with SUI. This study examines the costs of transobturator slings for SUI surgeries. A model was created to estimate the budget impact to hospitals of transobturator sling surgery in women with SUI. Current practice using transobturator slings including the MonarcTM Subfascial Hammock, Obtryx® Transobturator Mid-Urethral Sling System, Aris® Transobturator Sling System, Align® TO Trans-Obturator Urethral Support System, GYNECARE TVTTM Obturator System Tension-free Support for Incontinence and GYNECARE TVT ABBREVOTM Continence System were modeled. Four surgical complications were considered: re-operation due to failure, revision or removal of sling, urologic complications including urinary obstruction and urinary tract infection, and pelvic complications. This model calculates the average 1-year cost per patient with the use of each sling product and estimates the total budget for sling urinary incontinence surgery associated with each product based on these calculations. Average incremental cost over 1 year ranged from $2,601 (GYNECARE TVTTM Obturator) to $3,132 (Desara®) per patient. In a hypothetical population of 100 patients, a 10% shift from the most to the least expensive option was associated with a 2% decrease in hospital expenditures. With the current market share for transobturator sling products, the expected expenditure is around $285,533 for a surgical population of 100 patients. Sling costs account for approximately $105,526 (37%) of this cost, with complications comprising the remaining majority. This study represents the first comparative assessment of the costs of different sling options for stress urinary incontinence surgeries. GYNECARE TVT ABBREVOTM and GYNECARE TVTTM Obturator products represent a sound clinical and economic choice for hospitals. Moreover, the reduction in expenditures is obtained at the benefit of patients, who experience fewer complications and avoid complication-related procedures.

Analysis of the Impact of Obesity on Recurrence Rates of Stress Urinary Incontinence After Urethrolysis or Sling Revision

The impact of obesity on the recurrence rates of stress urinary incontinence (SUI) after urethrolysis/sling revision was analyzed. A retrospective analysis was conducted of patients who underwent urethrolysis or sling revision from January 2004 to November 2010. Data from 74 patients were included. The mean body mass index (BMI) was 29.8 kg/m (SD, 6.3) and 37/74 (50%) women were obese (BMI ≥ 30 kg/m) with a mean length of follow-up of 27 weeks (range, 6-132 weeks). The following urethrolysis/sling revision surgical techniques were varied: partial transvaginal urethrolysis, complete transvaginal urethrolysis, abdominal urethrolysis, sling transection, and transvaginal sling stretching.Of the 74 cases, 25 (33.8%) had recurrent SUI after urethrolysis or sling revision. The BMI did not differ between those who did and did not have a recurrence (t test P = 0.68); 25/49 (51%) women who did not have a recurrence were obese and 12/25 (48%) women with recurrence were obese. Obesity was not associated with increased rates of SUI recurrence after urethrolysis/sling revision.

Comparing the risk of urethrolysis for the treatment of voiding dysfunction between two retropubic mesh slings: a case-control study

Long-term outcome data exist with Gynecare TVT tension-free support for incontinence (TVT), yet few comparisons have been made to newer retropubic sling delivery systems, especially with regards to urethrolysis for postoperative voiding dysfunction. Our objective was to compare the odds of urethrolysis for the treatment of voiding dysfunction between two retropubic sling systems. We performed a case-control study comparing the risk of urethrolysis between TVT versus the Bard ALIGN Urethral Support System (Bard Align). We identified surgical procedures described as urethrolysis, sling revision, loosening, or lysis performed for the treatment of voiding dysfunction by urogynecologists at Duke University between January 2007 and June 2011. Slings placed at outside institutions were excluded. Controls were matched for both concomitant prolapse procedures and academic year. Of 818 total slings placed during the study period, there were 28 (3.4 %) urethrolysis cases, which were matched to 84 controls. Among urethrolysis cases, 6/28 (21.4 %) had received TVT, while 22/28 (78.6 %) had received Bard Align slings. Of the 84 matched controls, 30/84 (35.7 %) had undergone TVT and 54/84 (64.3 %) had undergone Bard Align. There was no significant difference in the odds of urethrolysis following the use of TVT or Bard Align [odds ratio (OR) 2.00, 95 % confidence interval (CI) 0.74-5.50]. In a conditional logistic regression model, which adjusted for age, body mass index, prior anti-incontinence or prolapse surgery, and postvoid residual, there remained no significant difference in odds of urethrolysis between the two sling types (OR 1.50, 95 % CI 0.42-5.33). Despite different instrument designs, there was no significant difference in the risk of urethrolysis following TVT or Bard Align retropubic sling.