Sling Revision Research Articles

Perceived health status after mid-urethral sling revision in 287 women from the VIGI-MESH registry: A cross-sectional study.

To evaluate the health status and recovery of women after mid-urethral sling (MUS) revision in response to complications. Cross-sectional study using a questionnaire sent to women from a registry. Twenty-two French surgical centres. A total of 287 women from the VIGI-MESH registry responded, having undergone MUS revision for complications. Our sample of women were compared against a representative set of French women taken from the Eurostat database. Multivariate analysis was performed to identify clinical predictors for successful MUS revision. A qualitative analysis was carried out on free-text comments. Health status, defined by the Minimum European Health Module, and recovery, assessed by Patient Global Impression of Improvement. The response rate was 76% (287/378), with 49% of the women (141/287, 95% CI 43%-55%) reporting good health status, which was 8 points lower than that expected from the comparator French set (57%, 95% CI 55%-58%). Overall, 53% (147/275, 95% CI 47%-59%) of the women reported feeling much better after MUS revision. Just over one-third (35%, 95/275, 95% CI 29%-40%) of respondents reported poor health with little or no improvement. Multivariate analysis showed that being operated on for pain at revision was associated with worse self-perceived health than being operated on for exposure (OR 0.36, 95% CI 0.14-0.95); women with pre-existing comorbidity reported a poorer health status following MUS revision (OR 0.22, 95% CI 0.13-0.38). Our results suggest that half of the women recovered good health status after MUS revision, whereas a proportion appeared to be seriously affected by an MUS complication despite the revision.

Continence Is Not Affected after Sling Revision with Transvaginal Tape Elongation for Post-Sling Voiding Dysfunction.

Voiding dysfunction (VD) after sling operation is not uncommon. Sling revisions by incision/excision are usually effective; however, they may result in recurrent stress urinary incontinence (SUI). We aimed to evaluate continence status after an innovative sling revision procedure that preserves the integrity of the sling. Patients who underwent either a single-incision (AJUST) or a trans-obturator (TVT-O) mid-urethral sling were studied. Transvaginal tape elongation (i.e., sling midline incision and mesh interposition) was performed on patients with post-sling VD. Factors that may affect recurrent SUI were investigated by statistical analyses. Of 119 patients, 90 (75.6%) (45 AJUST and 45 TVT-O) were available for long-term (median 9; 8-10 years) follow-up. A significantly higher rate (17.2% vs. 3.3%, p = 0.014) of VD was noted after AJUST (N = 10) than after TVT-O (N = 2). After sling revision, four (33%) of the 12 cases reported recurrent SUI, which was not significantly different (p = 1.000) from the rate (37%, 29/78) of patients who did not undergo sling revision. Further statistical analyses revealed no significant predisposing factors affecting the recurrence of SUI. Surgical continence did not seem to be affected by having had sling revision with transvaginal tape elongation for post-sling VD.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision.

The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence. We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure. Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04). The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis.

Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US. State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees. Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision. AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

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.

8681 Complications Among Patients Undergoing Mesh Graft Revision Surgery: A Retrospective Cohort Study of the NSQIP Database

<h3>Study Objective</h3> To compare complication rates among patients having urogynecology surgery for revision of a mesh graft placed for management of pelvic organ prolapse. <h3>Design</h3> A retrospective, population-based cohort study was conducted using the American College of Surgeons National Quality Improvement Program (NSQIP) database. A multivariable logistic regression analysis adjusting for age, race, smoking status, ASA category and concomitant procedures was completed. The outcomes were a composite of complications excluding urinary tract infections (UTI), and hospital readmission within 30 days. <h3>Setting</h3> Inpatient and outpatient mesh revision surgeries performed at community and academic hospitals captured in the NSQIP database from 2012 to 2019. <h3>Patients or Participants</h3> Patients undergoing mesh graft revision by urology or gynecology were classified into vaginal, abdominal or laparoscopic approach using Common Procedural Technology (CPT) codes. Patients having revision of a mid-urethral sling were excluded. <h3>Interventions</h3> Mesh graft revision surgery by vaginal, abdominal or laparoscopic approach <h3>Measurements and Main Results</h3> Of 1692 eligible patients, 1561 underwent vaginal, 74 underwent abdominal, and 57 underwent laparoscopic approach graft revision. The complication rate, excluding UTI, was 4.6% in the vaginal approach group, 12.2% in the abdominal approach group and 12.3% in the laparoscopic approach group (p<0.001). Compared to a vaginal approach, the abdominal approach group had higher odds of complications (abdominal: adjusted OR 2.76, 95% CI 1.30 – 5.83; laparoscopic: adjusted OR 1.86, 95% CI 0.73 – 4.72). The abdominal and laparoscopic groups had higher odds of readmission compared to the vaginal approach group (abdominal: adjusted OR 3.11, 95% CI 1.15 – 8.40; laparoscopic: adjusted OR 6.57, 95% CI 2.22 – 19.40). Clavien-Dindo IV complications were rare and only seen after vaginal surgery (0.4%, n=6). <h3>Conclusion</h3> Short term complications were uncommon after vaginal mesh graft revision surgery, and less common than following an abdominal approach.

Does Medicaid Cover Male Urethral Sling Surgery? A State-by-State Analysis

ABSTRACT Introduction Male suburethral slings are one treatment option for stress urinary incontinence (SUI) due to intrinsic sphincter deficiency post-prostatectomy in appropriately selected patients. Some studies report up to 55% social continence, and 23% of respondents reduced use of pads by greater than 50%. Male slings may be preferred in men with limited manual dexterity who have difficulty manipulating an artificial urinary sphincter, or in men with more mild SUI, particularly if there is no history of prior radiation. Existing literature regarding insurance coverage and physician reimbursement overwhelmingly focuses on Medicare and commercial plans, leaving a knowledge gap with respect to the Medicaid population which may contribute to inequitable utilization of this treatment modality for SUI. Objective To quantify Medicaid coverage for placement and revision of male suburethral slings for correction of male SUI by state. Methods State Medicaid websites were utilized to access publicly available physician fee schedules. Individual search queries were performed for CPT codes 53440 and 53442, which represent sling operation for correction of male urinary incontinence and removal or revision of sling for male urinary incontinence, respectively. Data were recorded for each device, including the coverage status and physician fees. Results Medicaid physician fee schedules were accessible for 49 out of 50 US states. All 49 of these states reported coverage for placement of a male urethral sling, and 48 states reported coverage for removal or revision of a male urethral sling. Means and range of physician reimbursement for each procedure were $834.26 ($198.00-$5,237.35) for placement of a male urethral sling (53440) and $616.88 ($104.27-$2,288.93) for removal or revision of a male urethral sling (53442). Conclusions Male suburethral sling placement and revision for SUI in the Medicaid population are covered by nearly all states as confirmed by publicly available data. Knowledge of Medicaid coverage for SUI related surgery may result in improvement in the utilization of this treatment option for male SUI and may improve quality of life in the Medicaid cancer survivorship population. Disclosure No

Lower urinary tract symptoms following sling revision in patients with urethral erosion from a midurethral sling

To determine if the location and degree of urethral erosion from a midurethral sling impacts resolution of lower urinary tract symptoms (LUTS). Retrospective chart review was done on patients who underwent surgery for urethral erosion from a midurethral sling. Clinic and hospital electronic medical records were searched for pertinent pre-, intra-, and post-operative data. Urethral erosions were classified as partial (dorsal or ventral) or complete, and location along the urethral length. Descriptive statistics was utilized to categorize data. Analysis for significance (p-value < 0.05) was performed with the student’s t-test, chi-square and Fisher’s Exact tests. Eight patients had urethral erosion from a midurethral sling (Table 1 shows demographics). Average time from midurethral sling placement to revision surgery was 42 months (range 12-168). Preoperatively, most patients (75%) had more than two LUTS: urinary incontinence (87.5%), urgency (75%), frequency (50%), voiding difficulty (50%), recurrent urinary tract infections (UTI) (37.5%); 87.5% also had pelvic organ prolapse, dyspareunia, pain. Table 2 shows location of urethral erosion and symptoms. The management of urethral erosions depended on their classification and location (1-transvaginal with urethrotomy and reconstruction, 2-transvaginal and cystoscopy assisted, and 3-transurethral/cystoscopy). All foreign bodies were removed from the urethral lumen at the initial surgery in 75% of patients, 2 needed additional procedures. At a mean follow-up of 8 weeks (range 3-60), 62.5% of patients had complete symptom resolution (p<0.03), 87.5% had no urinary incontinence (p<0.01), and urinary urgency improved (p<0.04). Only 3 patients (37.5%) reported symptoms (urgency, frequency, nocturia, SUI, voiding difficulty, slow stream, recurrent UTIs- each only 12.5%). In patients with urethral erosion from a midurethral sling, most can expect significant resolution of their lower urinary tract symptoms after sling revision with removal of all luminal mesh.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Incidence of Midurethral Sling Revision or Removal by Its Timing With Prolapse Surgery.

The aim of the study was to evaluate incidence of midurethral sling removal/revision based on timing with surgery for pelvic organ prolapse. This was a retrospective cohort study of women who underwent midurethral sling placement in a claims-based database of women 65 years or older. Three groups were identified using the Current Procedural Terminology codes: (1) isolated sling, (2) concomitant sling, and (3) prolapse surgery and staged sling after prolapse surgery. In the staged group, placement of sling was identified within 18 months after index prolapse surgery. Fascial grafts were excluded. Sling removal/revision was identified across 3 years after sling surgery using Current Procedural Terminology code 57287. Rates of sling removal/revision were calculated by group. Comparisons were made using the χ2 test and analysis of variance. Cumulative incidence of removal/revision was evaluated using the Kaplan-Meier curves. Cox proportional hazards was performed to evaluate factors influencing removal/revision. We identified 39,381 isolated MUSs, 25,389 concomitant, and 886 staged. The rate of sling removal/revision was 3.52%. Rates of removal/revision differed between groups (7% staged vs 3.94% concomitant vs 3.17% isolated sling, P < 0.001). Compared with the staged group, the rate of removal/revision was lower in the isolated sling group (relative risk, 0.4550; 95% confidence interval [CI], 0.358-0.568) and the concomitant group (relative risk, 0.5666; 95% CI, 0.4450-0.7287). After adjusting for patient characteristics, sling revision or removal remained significantly less in the isolated MUS (hazard ratio, 0.50; 95% CI, 0.39-0.65) and concomitant (odds ratio, 0.55; 95% CI, 0.43-0.71) groups. Sling removal/revision is higher when it is staged after prolapse surgery compared with isolated and concomitant placement. Future studies are needed to confirm these findings in a controlled population.

Long-Term Outcomes After Midurethral Mesh Sling Surgery for Stress Urinary Incontinence.

Although midurethral mesh slings are the criterion standard surgical treatment for stress urinary incontinence (SUI), limited data exist regarding long-term outcomes. Thus, our objectives were to evaluate the long-term risk of sling revision and the risk of repeat SUI surgery up to 15 years after the initial sling procedure and to identify predictors of these outcomes. Using a population-based cohort of commercially insured individuals in the United States, we identified women aged 18 years or older who underwent a sling procedure between 2001 and 2018. For sling revision, we evaluated indications (mesh exposure or urinary retention). We estimated the cumulative risks of sling revision and repeat SUI surgery annually using Kaplan-Meier survival curves and evaluated predictors using Cox proportional hazards models. We identified 334,601 mesh sling surgical procedures. For sling revision, the 10-year and 15-year risks were 6.9% (95% confidence interval [CI], 6.7-7.0) and 7.9% (95% CI, 7.5-8.3), with 48.7% of sling revisions associated with mesh exposure. The 10-year and 15-year risks of repeat SUI surgery were 14.5% (95% CI, 14.2-14.8) and 17.9% (95% CI, 17.3-18.6). Women aged 18-29 years had an elevated risk for both sling revision (hazard ratio, 1.20; 95% CI, 1.15-1.25) and repeat SUI surgery (hazard ratio, 1.30; 95% CI, 1.25-1.37) compared with women 70 years and older. In our study population, the 15-year risk of sling revision was 7.9%, with nearly half of revisions due to mesh exposure. These findings provide critical long-term data to support informed decisions for women and health care providers considering midurethral mesh slings.

Is it the Surgeon? A Re-examination of Mid-urethral Sling Complications

ObjectiveTo identify potential technical factors during initial mid-urethral sling (MUS) placement that contribute to subsequent sling revision procedures. MethodsA retrospective chart review was performed examining synthetic MUS reoperations at a single institution from 2008-2020. The implanting surgeon's operative note, when available, was critically reviewed with respect to trocar placement, sling location, and tensioning technique. The reoperative report was reviewed for aberrant intraoperative findings relating to the index surgery. ResultsA total of 306 women underwent revision of their MUS. Operative reports from the implanting surgeon were available for 276 (90.2%) women. Review of index operative reports revealed 47 unambiguous descriptions of improper technique, including 19 cases of described excessive tensioning and 2 cases of MUS placement despite noted urethral injury during the index case. Indications for reoperation were clinical obstruction (63%), pain (40%), and mesh erosion/exposure (33%). In 186 (67.4%) women, there was an intraoperative finding during the revision that likely contributed to the need for reoperation. Among these 186 women, 110 (59.1%) slings were noted to have been placed too proximally, 78 (41.9%) were over-suspended, and 57 (30.6%) were placed too deep in the periurethral fascia. ConclusionReview of the index operative note and findings at operative re-exploration of MUS surgeries, often reveals evidence that the initial MUS implantation was technically suboptimal. Such findings suggest that intraoperative surgical technique is a critically important factor contributing to postoperative complications in MUS surgery. This underscores the importance of surgical training and adherence to surgical principles during the placement of a synthetic MUS.

Management of post-operative urinary incontinence after midurethral sling explantation for pelvic or perineal pain.

The objective was to report the management of post-operative urinary incontinence after midurethral sling (MUS) revision for chronic pelvic pain (CPP), and to report functional outcomes. From November 2004 to February 2018, a total of 89 women who underwent removal or section of MUS for CPP, were enrolled. Patients were divided into the transobturator tape (TOT) group (50 patients) and the tension-free vaginal tape (TVT) group (37 patients); 2 patients had had both slings implanted. We report the rate of stress urinary incontinence (SUI) recurrence, the rate of de novo urge urinary incontinence (UUI), the need for subsequent SUI or UUI surgery, and functional outcomes (pain and continence). Median follow-up was 41.4months [0.9-138.8]. SUI recurrence or de novo UUI occurred in 52 cases (58.4%): 19 (51.3%) patients in the TVT group, 31 (62%) in the TOT group, and both patients (100%) who underwent total removal of both slings. Among patients with SUI recurrence or de novo UUI, 39 (75%) had pain relief after sling removal. Seventeen patients (32.6%) refused any treatment, 14 (26.9%) were cured with conservative therapy, and 21 (40.3%) underwent SUI or UUI surgery. One patient had de novo pelvic pain after reoperation. The overall continence rate for all patients who underwent sling revision was 82% (73 out of 89) at the last follow-up. After MUS revision for CPP, post-operative UI may occur in 58.4% of patients, of which, one-fourth may be managed with conservative measures only. Forty percent of them had redo surgery with a low risk of pain recurrence and a high rate of urinary continence.

Rates of Sling Procedures and Revisions-A National Surgical Quality Improvement Program Database Study.

The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication. This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant. During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = -0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = -0.49, -P = 0.51). Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.

Trends of Mesh Utilization for Stress Urinary Incontinence Before and After the 2011 Food and Drug Administration Notification Between FPMRS-Certified and Non-FPMRS-Certified Physicians: A Statewide All-Payer Database Analysis

ObjectivesTo investigate the utilization of mesh slings for stress urinary incontinence (SUI) across time – before and after the 2011 US Food and Drug Administration (FDA) public health notification regarding an increase in adverse events related to transvaginal mesh (TVM) for pelvic organ prolapse (POP) repair – and among FPMRS-certified urologists and gynecologists and non-FPMRS counterparts using a statewide database. MethodsThe New York Statewide Planning and Research Cooperative System all-payer database was utilized to extract outpatient Current Procedural Terminology procedure codes for SUI mesh sling utilization and revision or removal performed between 2007 and 2015. ResultsAfter the 2011 FDA warning on POP with TVM, sling placement decreased by 43% from 5214 cases in 2011 to 2958 in 2015. However, over the study period, the rate of sling revision remained stable relative to total sling placement. The rise and fall in mesh sling usage for SUI was primarily driven by non-FPMRS providers. FPMRS providers performed a higher proportion of sling procedures. The number of FPMRS physicians also increased from 2011 to 2015, and each individual physician had a higher median case volume for sling placements and revisions. ConclusionIn New York state, utilization of mesh slings for SUI has significantly decreased since the 2011 FDA public health notification, without any specific warning for the utilization of mesh in this setting. This trend was mainly driven by a decrease in mesh usage among non-FPMRS physicians, although the specific causality is likely complex.

141 - Sling revision for bladder outlet obstruction in women with primarily storage symptoms: What are the best urodynamic criteria to predict outcomes?

141 - Sling revision for bladder outlet obstruction in women with primarily storage symptoms: What are the best urodynamic criteria to predict outcomes?

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case–Control Study

OBJECTIVETo identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion. MATERIALD AND METHODSThis is a case–control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion. RESULTSIn total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m2 (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m2 (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]). CONCLUSIONSmoking status, age under 55 years, BMI below 30 kg/m2, fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Risk Factors for Returning to the Operating Room for a Second Surgery After Midurethral Sling for Stress Urinary Incontinence.

The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS). We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis. Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders. The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery.

Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p< 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.