Sling Excision Research Articles

Efficacy of Mid-Urethral Sling and Urethral Dilation for Stress Urinary Incontinence Combined with Urethral Stricture in Women.

To investigate the potential clinical benefits of mid-urethral sling (MUS) and urethral dilatation (UD) operations for the treatment of stress urinary incontinence (SUI) combined with urethral stricture. Descriptive study. Place and Duration of the Study: Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China, from January 2017 to 2022. Patients with Qmax <15ml/s or PVR >50ml, and video urodynamic study (VUDS) capable of confirming the presence and position of urethral stricture were included. The clinical efficacy was evaluated by International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, maximum flow rate (Qmax), and postvoid residual (PVR) urine. ICIQ-SF, Qmax, and PVR were measured presurgery, on postoperative 2-week, and 1-month postsurgery. There were total 19 patients with an average age of 61.37 ± 11.28 years (range 39-84) with SUI and urethral stricture. ICIQ-SF scores were decreased significantly at one month postoperatively compared with the preoperative [5.0 (0.0, 7.0) vs. 14.0 (13.0, 15.0), p <0.001]. Qmax was increased dramatically compared with the preoperative [21.3 (14.0, 28.4) vs. 13.0 (8.7,18.0), p <0.001], and PVR was decreased remarkably than the preoperative [0.0 (0.0,0.0) vs. 0.0 (0.0,60.0), p = 0.018]. Of 19 patients primarily managed with MUS and UD, two patients experienced recurrence requiring repetitive dilation till sling excision surgery was conducted, and improvement was evident in one patient after repeating UD. The overall incidence of SUI combined with urethral stricture in women is low. With a success rate of 89.5%, MUS and UD were effective therapies for the co-existence of SUI with urethral stricture, and repeated UD can be performed safely if necessary in long-term follow-up. Stress urinary incontinence, Urethral stricture, Mid-urethral sling, Urethral dilatation.

V12-07 ROBOTIC-ASSISTED TRANSABDOMINAL REMOVAL OF ERODED MID-URETHRAL MESH SLING

You have accessJournal of UrologyCME1 Apr 2023V12-07 ROBOTIC-ASSISTED TRANSABDOMINAL REMOVAL OF ERODED MID-URETHRAL MESH SLING Shreeya Popat, Gjanje Smith-Mathus, Alvaro Lucioni, and Una Lee Shreeya PopatShreeya Popat More articles by this author , Gjanje Smith-MathusGjanje Smith-Mathus More articles by this author , Alvaro LucioniAlvaro Lucioni More articles by this author , and Una LeeUna Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Depending on the indication for excision, there are multiple surgical approaches for the removal of mid-urethral mesh slings: transvaginal, endoscopic, open abdominal, and robotic. In this video, we demonstrate the robotic approach to treat mid-urethral mesh slings that have eroded into the bladder. The robotic approach offers excellent exposure, visualization, and accessibility. Compared to endoscopic approaches, the entire arm of the sling can be removed from the bladder wall, the bladder repaired, and the foreign body thereby completely eliminated from the bladder. Robotic mid-urethral mesh sling excision is ideal in any patient that would be best served by maximal removal of the mesh from the bladder in order to prevent future complications. METHODS: In this video, we display two different cases to show two unique approaches to robotic mid-urethral mesh sling excision depending on the location of the mesh sling erosion: 1) If a retropubic sling is eroded through the anterior bladder, we begin by dropping the bladder and entering the space of Retzius to locate the mesh arm. 2) If the sling is eroded into the posterior bladder, a cystotomy is made on the anterior dome to visualize the posterior bladder wall. RESULTS: Once the mesh is identified, we follow the mesh graft carefully and delicately and dissect it away from surrounding tissues. The dissection is immediately close to the mesh, without fragmenting it, to allow for complete excision. This also allows for protection of adjacent critical structures. The surgical principles and instrument techniques of robotic mesh excision mirror the surgical technique utilized for transvaginal mesh excision. CONCLUSIONS: For treatment of mesh erosion into the bladder, a robotic approach offers excellent visualization, is feasible, and well-tolerated. Compared to fragmenting the mesh using an endoscopic approach, the robotic approach has the advantage of excising the mesh definitively, eliminating the foreign body in the bladder and preventing future recurrences of mesh erosion. Properly selected patients should be offered the robotic approach to mesh excision. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1066 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shreeya Popat More articles by this author Gjanje Smith-Mathus More articles by this author Alvaro Lucioni More articles by this author Una Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

This Month in Adult Urology.

This Month in Adult Urology.

Prevalence and Predictors of Bladder Outlet Obstruction in Women With Chronic Urinary Symptoms and a History of Urethral Sling Surgery.

The objective of this study is to review patients with chronic urinary symptoms and remote urethral sling surgery to determine the prevalence and predictors of obstruction. A single-center retrospective review was performed on patients referred with chronic lower urinary tract symptoms (>6 months) and a history of urethral sling surgery. Obstruction was identified by urodynamics using the Blaivas criteria or fluoroscopy. Clinical findings for patients with and without obstruction were compared. Logistic regression was applied to identify predictors of urodynamic obstruction. The need for sling revision and post-revision outcomes were evaluated. In total 105 patients were included, median age 61 years (IQR 19), median time since sling surgery 5.0 years (IQR 8). Sixty percent (63/105) met the definition for obstruction. Patients with obstruction had higher mean detrusor pressure at maximum urinary flow rate (35 vs 19 cm H2O) and lower maximum urinary flow rate (6.0 vs 14 mL/s; P < .05). A tight suburethral band and increased post-void residuals were significantly associated with urodynamic obstruction (P < .05). Fifty-nine (59/105; 56%) patients underwent suburethral sling excision. The incidence of improvement in storage and voiding symptoms at 6 months was 43% and 87%, respectively. At 30 months post-excision, the probability of being incontinence-free was 56% (95% CI 41, 69) and the probability of being free from redo sling surgery was 75% (95% CI 55, 87). Obstruction is common in patients with chronic urinary symptoms and history of urethral sling surgery. Patients undergoing sling revision should be observed for persistent storage symptoms and recurrent incontinence.

Autologous pubovaginal sling for recurrent stress urinary incontinence after two or more failed synthetic midurethral sling

ObjectiveTo determine efficacy and safety of salvage autologous pubovaginal sling (PVS) placement after a two or more failed synthetic midurethral sling. MethodsWomen undergoing autologous PVS placement for two or more failed synthetic MUS between 2008 and 2019 were identified. Those patients were conducted a follow-up examination. Outcomes of surgery were assessed using the cough stress test with a full bladder and symptom questionnaire, including Incontinence Visual Analogue Scale (I-VAS) and Incontinence Quality of Life (I-QOL) questionnaire. Surgical results were categorized into three classes: cured, improved, and failed. Secondary measures included patients’ recommendation of autologous fascial sling (AFS). ResultsA total of 18 eligible patients met the criteria, of whom median age at surgery was 67 (52–74) years with a median follow-up of 80 (12–144) months. Preoperatively, all patients were identified by urodynamic test with Valsalva leak point pressure (VLPP) < 60 cmH2O. All patients had concomitant part sling excision combined with urethrolysis at the salvage operation. At the follow-up examination, sixteen in eighteen (88.89%) patients were cured and improved. The postoperative total score and each individual domain in I-QOL improved significantly compared with the baseline (p < 0.001). Postoperative I-VAS was significantly lower than preoperative (1.3 ± 0.6 vs. 7.8 ± 2.2, p < 0.001). A total of 16 patients (88.89%) recommended the AFS to others. Neither perioperative blood transfusions nor other complications above Clavien level 3 were observed. ConclusionsOur study indicates that autologous PVS is effective and safe in women with recurrent stress urinary incontinence after two or more failed synthetic MUS.

Persistent peri-anal vaginocutaneous fistula/sinus tract associated with chronically infected synthetic transobturator mid urethral slings

The objectives of our video are to highlight that persistent vaginocutaneous fistulas or sinus tracts can be associated with chronically infected macroporous (Type 1) synthetic transobturator slings, to discuss common presenting features and the importance of removal of the infected mesh and to demonstrate our surgical approach to excising chronically infected synthetic transobturator slings. We present a 61-year-old patient with a persistent non-healing right perianal vaginocutaneous fistula/sinus tract following incision and drainage of a right ischiorectal abscess 1 year prior. She has a history of transobturator tape sling placement 15 years prior for stress urinary incontinence and a subsequent vaginal mesh excision for vaginal mesh exposure 4 years prior. Her main complaint was persistent foul-smelling vaginal discharge and a non-healing right perianal wound. Despite undergoing multiple perianal debridement procedures her symptoms persisted. We had a high suspicion that her transobturator sling was the nidus for the persistent non-healing wound, thus we proceeded with an exam under anesthesia and right transobturator mesh excision. Removal of a transparent synthetic transobturator sling can be challenging. In this video we demonstrate our approach to removal of transobturator slings and discuss important surgical considerations to help with identification of transparent transobturator mesh slings. In conclusion, a strategic approach to transobturator synthetic mesh sling excision may allow for successful mesh identification and removal while minimizing complications.

A0573 - Continence outcomes in females post mid-urethral sling excision

A0573 - Continence outcomes in females post mid-urethral sling excision

Robotic Excision of Transobturator Midurethral Sling

Study Objective To identify indications for full transobturator (TOT) sling excision and to demonstrate techniques for full TOT sling excision in a patient with vaginal cutaneous fistula. Design Video demonstration of the procedure with narrated discussion. Setting Tertiary academic teaching hospital. Patients or Participants N/A. Interventions This video demonstrates techniques for performing safe and efficient TOT sling excision in a 65-year-old-female who developed persistent, chronic mesh-related infection with formation of a sinus tract and vaginal cutaneous fistula following TOT sling insertion 15 years prior. Measurements and Main Results N/A. Conclusion Full TOT sling excision may be required for persistent pain, mesh erosion, or mesh-related infections. Thorough understanding of pelvic anatomy, avascular spaces, and the TOT sling trajectory is required for safe and efficient sling removal. Approaching the sling excision through a minimally invasive abdominal route allows for excellent visualization and the ability to work in confined spaces. To identify indications for full transobturator (TOT) sling excision and to demonstrate techniques for full TOT sling excision in a patient with vaginal cutaneous fistula. Video demonstration of the procedure with narrated discussion. Tertiary academic teaching hospital. N/A. This video demonstrates techniques for performing safe and efficient TOT sling excision in a 65-year-old-female who developed persistent, chronic mesh-related infection with formation of a sinus tract and vaginal cutaneous fistula following TOT sling insertion 15 years prior. N/A. Full TOT sling excision may be required for persistent pain, mesh erosion, or mesh-related infections. Thorough understanding of pelvic anatomy, avascular spaces, and the TOT sling trajectory is required for safe and efficient sling removal. Approaching the sling excision through a minimally invasive abdominal route allows for excellent visualization and the ability to work in confined spaces.

PD32-02 LONG-TERM OUTCOMES AND COMPLICATIONS OF TRANSVAGINAL MESH REMOVAL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (PD32)1 Sep 2021PD32-02 LONG-TERM OUTCOMES AND COMPLICATIONS OF TRANSVAGINAL MESH REMOVAL Colby Souders, Andre Miranda, Fatou Sahor, Ramy Goueli, Gary Lemack, Philippe Zimmern, and Maude Carmel Colby SoudersColby Souders More articles by this author , Andre MirandaAndre Miranda More articles by this author , Fatou SahorFatou Sahor More articles by this author , Ramy GoueliRamy Goueli More articles by this author , Gary LemackGary Lemack More articles by this author , Philippe ZimmernPhilippe Zimmern More articles by this author , and Maude CarmelMaude Carmel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002033.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although the use of transvaginal mesh (TVM) had decreased significantly before its ban in April 2019, FPMRS specialists are still treating TVM complications and performing vaginal or open/robotic vaginal mesh removals (VMR) for mesh-related complications. We assessed long-term outcomes and complications of VMR at a tertiary care institution. METHODS: Following Institutional Review Board approval, a retrospective review of non-neurogenic women undergoing transvaginal and abdominal/robotic VMR with 6 months minimum follow-up was undertaken. Mid-urethral sling removals alone were not included. Using an electronic medical record, and a neutral reviewer not directly involved in the care of these women, data abstracted included demographics, provider notes, operative reports, imaging, outside medical records, peri-operative information, and follow-up to the last clinic visit. RESULTS: From 2006 to 2020, 111 patients met study criteria. Table 1 summarizes patient demographics. Presenting symptoms were pain for 71%, dyspareunia for 65%, mesh erosion in 71% and, finally, 4% of patients had mesh perforation into surrounding organs (bladder, rectum, urethra). 42% of patients had a prior VMR at an outside institution. VMR involved an anterior (60%), posterior (11%), anterior and posterior (10%) compartment vaginal mesh and sacrocolpopexy mesh (19%). 38% of patients required a concomitant sling excision. Two ureteral injuries and one rectal injury were repaired intraoperatively. One unrecognized rectal injury required readmission. Mean follow-up was 48 months (range of 6-138 months). Prolapse repair after VMR was needed in 11%, with 6% requiring a subsequent anti-incontinence procedure. VMR resulted in resolution of pain in 64% of patients and resolution of dyspareunia in 47% of patients. CONCLUSIONS: VMR complexity requires advanced surgical expertise. It may result in multiple surgeries, and has an unpredictable functional outcome for pain relief, sexual function, and/or continence/prolapse status. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e544-e545 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Colby Souders More articles by this author Andre Miranda More articles by this author Fatou Sahor More articles by this author Ramy Goueli More articles by this author Gary Lemack More articles by this author Philippe Zimmern More articles by this author Maude Carmel More articles by this author Expand All Advertisement Loading ...

Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling.

IntroductionPatients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.ObjectiveThe primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.MethodsFrom 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.ResultsAbout 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).ConclusionIn conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Incontinence outcomes after "second primary" compared to repeat midurethral sling for recurrent and persistent stress urinary incontinence.

The current study aims to assess the continence rate of a "second primary" midurethral sling (MUS) in women with recurrent/persistent stress urinary incontinence (SUI) after sling excision compared to a historical cohort who underwent a repeat MUS. A retrospective cohort study of women who underwent excision of a primary MUS and placement of a "second primary" MUS from 2009 to 2016 compared to a historical cohort who underwent a repeat MUS from 2006 to 2009. The primary outcome was continence rate, defined as "not at all" or "somewhat" to Urogenital Distress Inventory (UDI-6) SUI subscale questions. Secondary outcomes included assessment of symptom severity (UDI-6), symptom-specific quality of life, Incontinence Impact Questionnaire (IIQ-7), Medical and Epidemiologic Aspects of Aging (MESA), and Patient Global Impression of Improvement (PGI-I). Survey responses were available for 23/64 (36%) in the "second primary" MUS group versus 88/135 (65%) in the historical cohort. Mean follow-up in months, second primary: 41.8 ± 26.1 versus repeat: 36.2 ± 14.1, p = 0.16 and age (years): 56.4 ± 10.7 versus 59.8 ± 10.8, p = 0.19. Continence rates were 48% in "second primary" versus 56% in the repeat group (p = 0.50). Both groups had significant improvement in questionnaire scores postoperatively with no intergroup differences. Multivariable analysis demonstrated that odds of success did not differ between groups (adjusted odds ratio: 0.73, 95% confidence interval: 0.27-1.99). In women with recurrent/persistent SUI, repeat and "second primary" MUS procedures demonstrate similar success outcomes and improvement in UI symptom distress and QOL. Continued research is needed for this increasingly important clinical question.

Erosion of Mesh Mid-urethral Sling Into a Complex Urethral Diverticulum: Diagnosis, Evaluation, and Surgical Management

We present a case of an eroded mesh mid-urethral sling into a urethral diverticulum. Preoperative MRI and 3-dimensional translabial ultrasound aided in the identification and surgical approach. Vaginal excision of sling with urethral diverticulectomy and complex urethral reconstruction was performed. To the author's knowledge, this is the first case documented in the literature describing an eroded mesh mid-urethral sling into a urethral diverticulum.

Mid-urethral sling revision for mesh exposure-long-term outcomes of two surgical techniques from a comparative clinical retrospective cohort study.

To compare vaginal closure with versus without sling excision in the management of vaginal sling exposure following mid-urethral sling (MUS). Clinical retrospective cohort study. Tertiary urogynaecological centre in Australia. Women with urodynamic stress urinary incontinence (SUI) who had a MUS (n = 2823) during 1999-2017 with a follow-up period up to December 2018. Thirty-three women (1%) had sling exposure and 31 required surgical intervention (1%). Clinical review with analysis of surgical database and patient records. The primary outcome was successful closure and resolution of exposure-related symptoms without the need for re-surgery. Secondary outcomes were repeat procedure and recurrent incontinence following revision. Mean follow up was 103months. Of the 20 women with a primary excision and closure approach, 19 had successful closure. Seven of 11 women with simple vaginal closure without excision needed another surgery for recurrent mesh exposure. Recurrence of stress incontinence did not occur in any of the four who had 'successful' closure without excision. Of those who had sling division/removal without a concomitant stress continence procedure, 32% (7/22) required further surgery. Sling excision and repair have better outcomes with less recurrence of sling exposure compared with simple closure. Following sling removal, one of three women will develop SUI recurrence and require surgery. TWEETABLE ABSTRACT: #Slingexcision &repair leads to less recurrence of exposure versus #simpleclosure for #slingmeshexposure.

Exploring stress urinary incontinence outcomes after sling excision for perforation or exposure.

This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS). A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure. In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99). Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.

Long-term results of transurethral endoscopic excision using the holmium laser for urethral perforation of synthetic slings.

This study reports on the long-term results of transurethral endoscopic excision using the Holmium laser (TEEH) for large urethral perforation (UP; defined as involving one-quarter or more of the urethral circumference) from synthetic slings. Charts of women treated with TEEH for large UP were reviewed. TEEH was performed using a 365-μm laser fiber passed inside an open-ended ureteral catheter positioned in a holmium laser enucleation of the prostate (HoLEP) sheath to stabilize the laser fiber. Data extracted included patient demographics, clinical presentations, surgical details, postoperative functional outcomes and complications, and any secondary repairs. From 2011 to 2016, 12 women underwent TEEH. The mean interval between sling placement and first TEEH was 47 months (range 10-161 months). The types of slings included transvaginal tape (n = 2), transobturator tape (n = 4), mini-invasive (n = 4), and Solyx (1), or were not specified (n = 1). The mean number of TEEH procedures was 1.6 (range 1-3), and the mean length of initial treatment was 40 min (range 15-79 min), with subsequent treatments <30 min. Mean follow-up time was 43 months (range 14-70). Resolution of UP by TEEH alone was achieved in 6 patients, with 2 requiring multiple TEEH. Six patients underwent secondary vaginal mesh sling excision alone or with an associated repair including 2 small distal urethrovaginal fistulas. TEEH is a minimally invasive procedure that can avoid a more complex initial urethral reconstruction and should be considered for treating large UP. Secondary repairs for residual small UP or associated lower urinary tract symptomatology may be necessary and patients should be counseled accordingly.

28: Management of intravesical mesh and incisional pain after midurethral sling placement

The objective of this video is to demonstrate the laparoscopic excision of an intravesical midurethral sling with concurrent removal of the sling arm through a suprapubic skin incision. This video describes the excision of both intravesical midurethral sling and incisional pain temporally related to the same surgical procedure. The patient described is a 48 year old who underwent Lynx retropubic midurethral sling placement at an outside facility. Review of her operative note revealed the fact that there was gross hematuria with bladder drainage after sling placement, however cystoscopy demonstrated no evidence of bladder injury. One week later, she developed a large hematoma and underwent evacuation, with an incision made through her left suprapubic incision. She presented to our practice 10 months later with urgency, frequency, recurrent urinary tract infections, and left sided incisional pain. Physical examination revealed significant tenderness and nodularity along her left suprapubic incision. Cystoscopy demonstrated a 2 cm intravesical portion of the midurethral sling penetrating the left dome of the bladder. The decision was made to proceed with laparoscopic removal of the intravesical mesh and complete removal of the left sided sling arm through a small suprapubic incision. Management of both intravesical midurethral sling and incisional pain is able to be accomplished using a laparoscopic approach with extraction through prior suprapubic incision.

33: Robotic excision of pubovaginal sling

33: Robotic excision of pubovaginal sling

16: Anterior and medial thigh anatomy in female cadavers: Clinical applications to transobturator tape sling excision

16: Anterior and medial thigh anatomy in female cadavers: Clinical applications to transobturator tape sling excision

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures.

Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement. This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment. Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better. The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Sling Incision is Not Always Sufficient

Objectives: To review various erroneous diagnoses assigned to symptomatic women after MUS incision, and report our outcomes after MUS excision in these women. Materials and Methods: Following IRB approval, a retrospective review of a prospectively collected MUS removal database was performed for non-neurogenic women who presented with continued LUTS despite a prior sling incision. Data reviewed by a neutral investigator not involved in patient care included demographics, presenting symptomatology, and outcomes after sub-urethral sling excision. Results: From 2006-2015, 18 patients were identified. Mean age was 55 + 12 years. Median time from initial placement to sling incision was 12 (range 1-108) months. Following sling incision, residual LUTS were treated with various therapies but without LUTS resolution. Indications for sling excision were obstruction (3), obstruction and pain (2), persistent vaginal pain/dyspareunia (9), recurrent vaginal exposure/dyspareunia (2), worsening urgency incontinence (1) and mixed urinary incontinence (1). Median time from sling incision to sling excision was 55 (range 5-146) months. Median follow-up after MUS excision was 12 months (range 6-45 months). Obstruction (5) and exposure (2) were all cured. Vaginal pain and dyspareunia improved in 8 of 11 women and UUI improved in one. Three women had persistent SUI and 1 developed recurrent SUI. Two women were treated satisfactorily with bulking agents, one with fascial sling and one with bulking agent followed by a fascial sling. Conclusions: Sling incision may not always resolve LUTS. In a subset of women, sling excision may eventually be needed, with variable outcomes.