Sling Revision Research Articles

Current Role of Urethrolysis and Partial Excision in Patients Seeking Revision of Anti-incontinence Sling

(Abstracted from Female Pelvic Med Reconstr Surg 2019;25:409–414) Stress urinary incontinence (SUI) affects 5% to 30% of women. After the introduction of the first synthetic midurethral sling (transvaginal tape) in1996, there was a rapid rise in the number of midurethral slings available, and these products were widely adopted and used.

02: The effect of music listening on preoperative anxiety in female pelvic medicine and reconstructive surgery: A randomized controlled trial

Preoperative anxiety has been associated with increased postoperative pain and lower patient satisfaction. The purpose of this study was to evaluate the effect of listening to music just prior to surgery on preoperative anxiety compared to usual care in patients undergoing reconstructive pelvic surgery. Patients scheduled for reconstructive pelvic surgery at our tertiary care center were enrolled on the day of their surgery approximately 45 minutes prior to the anticipated surgery start time. Following consent, all participants completed the Spielberg State Trait Anxiety Inventory Y1 (STAI-Y1) to measure baseline state anxiety levels prior to surgery. Demographic information, past surgical history, and a questionnaire regarding musical background and preferences were collected. Participants were then randomized to either the usual care (control group) or listening to music on headphones (music intervention group). Those in the music group could choose between several genres of prerecorded music. After 30 minutes, the STAI-Y1 questionnaire was re-administered. The primary outcome was the change in anxiety score as measured by the STAI-Y1. Descriptive statistics, T-tests, and Fisher's Exact Test were used to analyze the data. Sixty-six women completed the study; 34 participants in the control group and 32 participants in the music group. Racial/ethnic distribution, age, prior history of surgery, and music background and preferences were similar amongst those in the control group and the music group. Surgical indications included one or more of the following diagnosis: pelvic organ prolapse (44%), stress urinary incontinence (34%), urge urinary incontinence (6%), mesh exposure (5%), vaginal mass/diverticula (5%), genitourinary fistula (4%), and sling revision (2%). Participants reported that they found classical music (26%), soft rock (26%), country (17%), jazz (11%), and gospel music (10%) most relaxing. Baseline STAI-Y1 scores on the day of surgery were similar between the two groups (37.29 ± 11.57 in control group vs. 37.25 ± 9.02 in music group). STAI-Y1 scores significantly improved in the music group after 30 minutes of music listening compared to the control group (-6.81 vs. -1.59, P = 0.006). Patients undergoing reconstructive pelvic surgery present with moderate anxiety on the day of surgery. Allowing patients to listen to their preferred music is a simple intervention that may lower preoperative anxiety in this patient population.

20: Urinary tract infection following midurethral sling

Urinary tract infections (UTIs) are common in women following urogenital surgery and are associated with significant individual and societal burdens. Therefore, the need to further understand clinical risk factors and subsequent strategies for prevention is imperative. The purpose of this study is to identify risk factors for post-operative UTIs following midurethral sling (MUS). We also describe the bacterial species responsible for postoperative UTIs in our community and the antibiotics prescribed. This is a retrospective analysis of patients who underwent MUS from 2010-2018 within a FPMRS practice of 2 surgeons. Data was extracted from review of charts and UTIs were documented up to 12 months following MUS. Risk factors evaluated included patient factors (age, BMI, parity, medical comorbidities, urinary incontinence, post void residual (PVR), smoking history, prolapse stage, vaginal estrogen use, menopausal status, recurrent UTI history, sexual activity, pessary use, hormone replacement use, neurogenic bladder), surgical factors (operative time, antibiotic use, estimated blood loss, concomitant reconstructive surgery, bladder perforation) and postoperative factors (duration of voiding dysfunction, sling revision, urinary incontinence resolution, PVR at 6 week visit). Categorical variables were analyzed with the Chi-square test, and continuous variables were analyzed using Student’s t-tests. Statistically significant demographic and perioperative characteristics were studied in the Multiple Regression Analysis. 915 MUS cases were reviewed. 23% of patients developed at least 1 UTI in the 12-month period postoperatively. On a bivariate analysis, statistically significant associations were found between postoperative UTI and patients with higher age, greater BMI, stage 3 prolapse, recurrent UTI history, asymptomatic bacteriuria, and cardiovascular disease. Significant perioperative characteristics included concomitant reconstructive surgery, voiding dysfunction requiring catheterization, continued post-operative urinary incontinence, and elevated PVR. On a multivariate analysis, prior history of recurrent UTI and PVR >100mL at 6 weeks were associated with UTI postoperatively. A history of recurrent UTIs and UTI within the first 6 weeks postoperatively was both independently associated with development of recurrent UTI in the first year following MUS. Escherichia coli was the predominant bacterial species of both recurrent and nonrecurrent UTIs, and macrobid was the most common antibiotic utilized. This study provides additional power and confirmation of risk factors involved with postoperative UTIs following earlier studies of this topic. Local bacterial species and treatment patterns are described.

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.

A comprehensive look at risk factors for mid-urethral sling revision surgery.

The objective of this study was to identify risk factors and urodynamic parameters predictive of mid-urethral sling (MUS) revision surgery that can be used for counseling patients and individualizing risk prediction. Retrospective case-control analysis of 40 sling revisions performed during the 12-year study period were compared to 123 control cases that did not require revision to obtain a 1:3 case-to-control ratio. Demographic, perioperative, and urodynamic data were analyzed, with p < 0.05 as significant. Independent predictors of sling revision were assessed by binary logistic regression models, with risk expressed as adjusted odds ratios. After multiple regression analysis, younger age at time of index MUS placement (aOR 0.93, 95% CI 0.88-0.97), increasing number of cesarean deliveries (CD) (aOR 2.00, 95% CI 1.01-3.96), and concomitant apical prolapse repair during index MUS procedure (aOR 4.63, 95% CI 1.34-15.93) were significant predictors of sling revision. Young age at the time of placement, multiple CD, and concomitant apical prolapse repair were independent factors predictive of sling revision. Giving consideration to risk factors could improve patient counseling and surgical candidate selection.

A Retrospective Analysis of Surgical Outcomes and Risk Factors for Persistent Postoperative Symptoms Following Synthetic Mid Urethral Sling Revision.

The purpose of our study was to describe the symptom profile of patients who presented to a tertiary care hospital for sling revision, define the efficacy of sling removal/revision in alleviating symptoms and identify what factors, if any, contribute to favorable surgical outcomes. We retrospectively reviewed the records of patients who underwent revision of a synthetic mid urethral sling at our institution between 2004 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from analysis. The outcomes assessed were the AUASI (American Urological Association Symptom Index) score, the M-ISI (Michigan Incontinence Symptom Index) score, pad use, post-void residual urine volume, examination findings and subjective improvement. A total of 430 patients met study inclusion criteria, of whom 182, 172 and 40 received a transobturator tape, a retropubic mid urethral sling and a mini-sling, respectively. Patients presented with 4 primary complaints, including mesh exposure or erosion, pain or dyspareunia, incontinence and/or bladder outlet obstruction. Of the patients 77% presented with at least 2 categories of symptoms. Average followup was 15 months. Postoperatively the AUASI score decreased from 19.0 to 14.7 (p <0.001) and the bother score decreased from 5.0 to 3.4 (p <0.001). The M-ISI also improved from total and bother scores of 15.7 and 4.4 to a postoperative average of 13.2 and 3.1 (p = 0.002 and <0.001, respectively). During this time approximately 40% of patients who presented with pain had persistent postoperative discomfort, in 20% with obstruction that condition failed to resolve and recurrent mesh complaints developed in 5% with mesh exposure or erosion. On multivariate analysis preoperative narcotic use was a significant risk factor for persistent postoperative pain (OR 6.9). Despite complex patient presentations subjective and objective urological symptom measures significantly improve following mid urethral sling revision.

Identification of Modifiable and Non-Modifiable Factors Associated With Mid-Urethral Sling Revision Surgery [40S

INTRODUCTION: The objective of this study was to identify modifiable factors and urodynamic parameters predictive of mid-urethral sling (MUS) revision surgery that can be used for counseling patients and individualizing risk prediction. METHODS: Retrospective analysis of 56 sling revisions performed during the 12-year study period. Those with complete medical records (n=40) were matched to 123 control cases that did not require revision, randomly selected from a total of 946 procedures to obtain a 3:1 control: case ratio. Demographic, history, patient reported symptoms, urodynamic study results, intraoperative data, and post-operative data were collected. RESULTS: Significant demographic findings predictive of sling revision included younger age (52.95 vs. 64.48 years, p<0.001) and greater than two previous cesarean deliveries (OR 13.556, 95% CI 1.468-125.137, p=0.013). Presence of posterior pelvic organ prolapse (OR 0.302, 95% CI 0.163-0.803, p=0.011), retropubic sling (OR 2.685, 95% CI 1.037, 6.955, p=0.037) and concomitant apical prolapse repair procedure (OR 3.086, 95% CI 1.299-7.332, p=0.009) was significantly associated with the revision group. Urodynamic factors were not predictive, except a maximum urethral closure pressure less 40 cm H2O was found to be protective (OR 0.0394, 95% CI 0.159-0.978). After multiple regression analysis, younger age, increasing number of cesarean deliveries, and concomitant apical prolapse repair retained statistical significance. CONCLUSION: Urodynamic studies were not useful in determining revision risk as compared to patient age, previous surgical history, and concomitant procedures.

Can Urodynamic Parameters Predict Sling Revision for Voiding Dysfunction in Women Undergoing Synthetic Midurethral Sling Placement?

The objective of the study was to evaluate the utility of urodynamic studies performed before primary midurethral sling placement for stress urinary incontinence in predicting the need for subsequent sling release for voiding dysfunction. The health records of women managed with primary synthetic midurethral sling placement at Mayo Clinic (Rochester, MN) from January 1, 2002, to December 31, 2012, were reviewed. The primary outcome was surgical sling release for postoperative voiding dysfunction (ie, prolonged retention, elevated postvoid residual volumes with new voiding symptoms, or de novo onset or worsening of overactive bladder symptoms). Logistic regression models were used to evaluate associations between potential clinical risk factors and the primary outcome. Overall, 1629 women underwent primary synthetic midurethral sling placement during the study time frame, including 1081 patients (66%) who underwent a preoperative multichannel urodynamic evaluation. A sling release for voiding dysfunction was performed for 51 patients (3.1%) at a median of 1.9 months postoperatively (interquartile range, 1.3-9.3 months). Patients undergoing sling release were significantly more likely to have had retropubic sling placement (P = 0.003) and concomitant prolapse surgery (P = 0.005). On univariate analysis, no urodynamic parameters were associated with the risk of sling release; evaluated parameters included peak flow rate (P = 0.20), postvoid residual volume (P = 0.37), voiding without detrusor contraction (P = 0.96), and detrusor pressure at maximal flow (P = 0.23). Sling release for voiding dysfunction was rare in our cohort. No urodynamic parameters were associated with the risk of sling release.

Predictors of sling revision after mid-urethral sling procedures: a case-control study.

To identify patient characteristics and surgical factors predictive of complications requiring mid-urethral sling (MUS) revision/removal. Case-control study. Tertiary academic centre in Canada. One hundred and seven women undergoing MUS revision/removal between 2005 and 2016 were matched with 214 controls by date of index MUS procedure (2:1 ratio). Data on patient and surgical factors were obtained via manual electronic and paper chart review. Three sets of pre-specified simple and multivariable logistic regression models were fitted to: (1) examine previously reported risk factors for MUS revision after primary surgical treatment; (2) identify preoperative predictors of MUS complications requiring revision/removal; and (3) identify surgical factors associated with this outcome after adjusting for potential confounding factors. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) for patient and surgical factors. The median time to MUS revision was 153 days (interquartile range, IQR 49-432 days). Active smoking status (OR 2.29, 95% CI 1.13-4.63, P = 0.03), having had a previous hysterectomy (OR 3.88, 95% CI 2.02-7.46, P < 0.01), and undergoing concomitant pelvic organ prolapse surgery at the time of the index MUS procedure (OR 2.63, 95% CI 1.32-5.52, P < 0.01) were independently associated with the need for MUS revision/removal. Sling type (obturator versus retropubic), method of tensioning (to cough versus over instrument), anaesthetic type, and estimated blood loss were not associated with this outcome in the analysis presented here. Active smoking status, having had a previous hysterectomy, and undergoing concomitant surgery for pelvic organ prolapse are risk factors for requiring subsequent MUS revision/removal. Risk factors for sling revision include smoking, previous hysterectomy, and concomitant prolapse surgery.

Revision Surgery for Undercorrected Blepharoptosis After Frontalis Sling Operation Using Autogenous Fascia Lata.

Undercorrected blepharoptosis can be encountered after frontalis sling operation. Revision surgery for undercorrection has commonly involved introducing a new sling material. We describe and evaluate a simple surgical technique to correct undercorrection by adjusting preexisting fascia. This is a retrospective interventional case series of patients undergoing sling revision between February 2010 and February 2017. Skin incision was made on the previous incision line. Careful dissection was performed superiorly to identify a preexisting fascia, and the dissected fascia was reattached to the tarsal plate using nonabsorbable sutures with adjustments for eyelid height and contour. The success of the procedure was defined as less than 1 mm of difference in the marginal reflex distance 1 of both eyes without any contour deformity. Twenty-one eyelids in 18 patients were included with a mean follow-up of 17.5 months (range 6-48) and a mean age of 14.7 years (range 5-57). All patients had undergone frontalis sling with autogenous fascia lata for congenital ptosis. Undercorrection due to recurrent ptosis was found in 12 eyelids, and contour deformity such as temporal ptosis was found in 9 eyelids. The mean time interval between previous frontalis sling operation and sling revision was 6.8 years. Nineteen patients (90.5%) achieved surgical success and a cosmetically acceptable appearance. Sling revision is a simple and effective method with low perioperative morbidity for cases of undercorrection or contour deformity following frontalis sling operation using autogenous fascia lata, even long after the primary procedure.

Risk Factors for Incomplete Bladder Emptying After Prolapse Repairs and Slings.

The aim of this study was to determine the risk factors for catheter use and incomplete bladder emptying (IE) more than 1 week after prolapse repairs and slings. This is a case-control study of women with prolapse repairs and/or sling from June 2011 to April 2016. All underwent standardized postoperative voiding trial before discharge. Controls and cases of IE were identified by codes and chart review; cases were defined as those needing any postoperative catheterization. We excluded patients with preoperative catheter use or postvoid residual (PVR) greater than 150 mL and those needing postoperative catheterization for reasons other than IE. Univariate and multivariate analyses were performed. A total of 475 (30.6%) cases and 478 controls were identified from 1552 eligible patients. Any catheter use was associated with higher uroflow PVR (71.2 vs 54.1 mL, P = 0.006), lower uroflow maximum flow (19.4 vs 25.4 mL/s, P < 0.001), and less detrusor overactivity (DO) (22.0% vs 28.7%, P = 0.03). Seventy-seven (5.0%) patients used catheters more than 1 week, and 15 patients (1.5%) required sling revision.Factors on multivariate analysis associated with any catheter use include office PVR [odds ratio (OR), 1.004; 1.00-1.008], uroflow maximum flow (OR, 0.96; 0.94-0.98), sling (OR, 2.40; 1.51-3.81), and anterior repair (OR, 1.81; 1.15-2.85). Factors associated with IE more than 1 week include uroflow maximum flow (OR, 0.90; 0.84-0.95), DO (OR, 0.21; 0.05-0.83), sling (OR, 3.68; 1.32-10.20), and uterosacral suspensions (OR, 3.43; 1.23-9.54). Overall, the incidence of short-term catheter use was 31%, prolonged IE more than 1 week was 5%, and 1.5% required sling revision. Sling placement, lower maximum flow, and higher preoperative PVR, anterior repair, and uterosacral ligament suspension are risk factors for IE, and presence of DO is protective.

Preoperative and Surgical Risk Factors for Complications Requiring Sling Revision or Removal after Midurethral Sling Procedures: a Case-Control Study

Objectives: Midurethral sling (MUS) surgery is the most commonly performed procedure for treatment of stress urinary incontinence worldwide. Approximately 3% of patients undergoing incontinence surgery with mesh require re-operation for mesh complications within 10 years. We sought to identify patient characteristics and surgical factors predictive of complications requiring MUS revision/removal.

MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION?

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy III1 Apr 2018MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION? Elizabeth Dray, Anne Pelletier Cameron, Erin Crosby, Ashley Grable, J Quentin Clemens, John Stoffel, Priyanka Gupta, and Paholo Barboglio-Romo Elizabeth DrayElizabeth Dray More articles by this author , Anne Pelletier CameronAnne Pelletier Cameron More articles by this author , Erin CrosbyErin Crosby More articles by this author , Ashley GrableAshley Grable More articles by this author , J Quentin ClemensJ Quentin Clemens More articles by this author , John StoffelJohn Stoffel More articles by this author , Priyanka GuptaPriyanka Gupta More articles by this author , and Paholo Barboglio-RomoPaholo Barboglio-Romo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2094AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Synthetic mid-urethral slings (MUS) are the most commonly performed treatment for stress urinary incontinence in women. While these procedures are typically safe and effective, complications do occur. The goal of our study was to define the presentation and outcomes of patients who underwent revision/removal of synthetic MUS at our institution. METHODS We performed a retrospective review of 432 women who underwent revision of a synthetic mid-urethral sling at our institution between 2005 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from our analysis. The outcomes assessed were AUA SI, Michigan Incontinence Symptom Index (M-ISI), pad use and post-void residual (PVR). RESULTS Average patient age was 53 and parity was 2.5. The majority of patients had a TVT (172) followed by TOT (182) and minisling (40). The remainder of slings were MUS of unidentified type. Eighty-one patients had undergone prior mesh revisions elsewhere. Patients presented with four primary complaints: mesh exposure or erosion, pain or dyspareunia, incontinence and bladder outlet obstruction. Most patients presented with at least two categories of mesh-related complaints, with the most common presentations being incontinence/pain (84 patients) and mesh exposure/pain/incontinence (74 patients). Patients most commonly underwent partial or complete excision of the vaginal portion of their mesh (110 and 248 patients respectively). Multiple mesh revisions were performed on 43 patients. Average follow-up was 14 months. The majority of patients (302) did not require further incontinence procedures at our institution. Forty-one patients had a sling placed at the time of mesh revision and 89 patients underwent procedures for incontinence at a later date. Clinically and statistically significant improvement was demonstrated on both validated questionnaires postoperatively. The number of patients reporting pain or dyspareunia declined (p<0.001), as well as the number reporting incontinence of any kind (p=0.006). PVR improved from a preoperative average of 91 cc to 48 cc postoperatively (p=0.001) and average pad use improved from 2.1 pads per day to 1.5 pads per day(p=0.003). CONCLUSIONS Despite complex patient presentations, subjective and objective urologic symptom measures significantly improve following MUS revision. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1008 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Elizabeth Dray More articles by this author Anne Pelletier Cameron More articles by this author Erin Crosby More articles by this author Ashley Grable More articles by this author J Quentin Clemens More articles by this author John Stoffel More articles by this author Priyanka Gupta More articles by this author Paholo Barboglio-Romo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

04: A retrospective study reviewing the risks related to recurrence of stress incontinence following revision of midurethral sling

04: A retrospective study reviewing the risks related to recurrence of stress incontinence following revision of midurethral sling

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.

Outcomes and Characteristics of Patients Undergoing Surgical Management for Mesh Related Complications.

The aims of this study were to describe the characteristics of women presenting with mesh-related complications and evaluate postoperative quality of life, sexual functioning, and patient-perceived outcomes. This institutional review board-approved study included a retrospective chart review and a cross-sectional follow-up with validated questionnaires. Demographics and medical histories were collected from charts of women treated for mesh-related complaints between 2010 and 2014. Subjects completed follow-up validated questionnaires regarding health, sexual functioning, postoperative symptom improvement/severity, satisfaction, and regret with the decision to pursue treatment. Ninety-three charts were analyzed. Mean subject age was 55 years, median body mass index was 28.7 kg/m, and median time from mesh placement to presentation was 2.7 years. Forty-nine had midurethral sling mesh only, 30 had prolapse-related mesh, and 14 had both. Forty-two subjects (48.9%) had mesh exposures, 19 involving prolapse-related mesh (52.4% transvaginal and 47.4% sacrocolpopexy). Surgical revisions were most often for exposure and pain. Seventy-five women were reached for follow-up; 71 agreed to participate, 53 (75%) returned the questionnaires. Thirty had sling revision, 22 had prolapse mesh revision, and 1 had both. Questionnaire results revealed no changes in health or sexual function after treatment. Postoperatively, subjects reported symptom improvement, low symptom severity, as well as high satisfaction and low regret with the decision to pursue surgical intervention. Women with mesh complications presented 2 years after initial placement, most often complaining of exposure or pain/dyspareunia. Although no changes in health or sexual functioning were noted postoperatively, participants reported symptom improvement after revision and satisfaction with the decision to pursue treatment.

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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.

Evaluation and Management of Voiding Dysfunction Following Surgery for Mesh Excision

Despite high success rates of midurethral slings for treatment of stress urinary incontinence, there is a known risk of de novo post-operative voiding symptoms. No clear management strategies exist to guide counseling or treatment specifically for persistent voiding dysfunction following sling revision or excision. The varying definitions of “voiding dysfunction” in the literature limits the ability to draw conclusions about the optimal treatment for a particular patient. While sling revision appears to be successful in treating urinary retention, there is less evidence on efficacy in patients with primary complaints of urgency, frequency, and voiding symptoms. There is limited evidence regarding third line overactive bladder (OAB) treatments in patients with refractory non-obstructive OAB after prior sling surgery. Resolution of obstructive and storage symptoms after sling revision is variable, and patients may require further intervention. Development of standardized definitions for voiding dysfunction and incomplete emptying is necessary to clarify evidence-based treatment recommendations.

MP40-05 USING DATA FROM THE CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) TO DETERMINE THE 30-DAY COMPLICATION RATE FROM URETHRAL-SLING PLACEMENT.

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy I1 Apr 2017MP40-05 USING DATA FROM THE CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) TO DETERMINE THE 30-DAY COMPLICATION RATE FROM URETHRAL-SLING PLACEMENT. Kai Dallas and Christopher Elliott Kai DallasKai Dallas More articles by this author and Christopher ElliottChristopher Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1252AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgical intervention for stress urinary incontinence is common with 200,000 repairs annually. The most common repair is mid-urethral sling placement. Although the long-term complication rate after a sling procedure has been rigorously studied, the short -term (30 day) complication rate has been incompletely assessed. We sought to evaluate unplanned hospital visits within 30 days of sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. METHODS With approval from the California Protection of Human Subjects committee, we accessed non-public data from the Office of Statewide Health Planning and Development (OSHPD) in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (CPT 57288) were identified, excluding other procedures aside from cystoscopy. All emergency department visits, inpatient admissions, and sling revision operations within 30 days of the original surgery were identified. We also examined the most common primary diagnoses associated with emergency department visits. RESULTS 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure (aside from cystoscopy). 1,630 patients had at least one unplanned hospital visit (5.7%) within 30 days. This included 1,327 emergency department visits (4.7%), 295 inpatient admissions (1.0%) and 79 sling revisions (0.28%). The hospital visit rate was significantly higher in patients undergoing a third or fourth sling placement (14.3%) as compared to a first or second sling placement (5.7%) (p=0.02) (table 1). Urinary retention and Foley catheter problem were the most common emergency department visit diagnoses (18.7% of ER visits), followed by urinary tract infection (9.3% of ER visits). CONCLUSIONS One in eighteen females will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits. Our findings can be used to improve patient counseling and suggest target areas to decrease unnecessary emergency department visits in the early postoperative period. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e524-e525 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Kai Dallas More articles by this author Christopher Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California

IntroductionAlthough long-term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. MethodsUsing data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. ResultsOf the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. ConclusionsOverall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.