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

Abstract

Objective To compare vaginal closure with versus without sling excision in the management of vaginal sling exposure following mid‐urethral sling (MUS). Design Clinical retrospective cohort study. Setting Tertiary urogynaecological centre in Australia. Population 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%). Methods Clinical review with analysis of surgical database and patient records. Main outcome measures 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. Results Mean follow up was 103 months. 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. Conclusion 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.

Symptomatic improvement after mesh removal: a prospective longitudinal study of women with urogynaecological mesh complications

“…Karmakar et al. reported success rates of 95% when mid‐urethral sling mesh was partially excised in patients with mesh exposure 34 . It is unclear whether partial excision, as opposed to complete excision as performed in this study, would be as effective for patients with pain.…”

“…Karmakar et al reported success rates of 95% when mid-urethral sling mesh was partially excised in patients with mesh exposure. 34 It is unclear whether partial excision, as opposed to complete excision as performed in this study, would be as effective for patients with pain. We also found that opioid use was high in this population and future studies will aim to describe opioid use in this study population in more detail.…”

“…There was no difference in postoperative outcomes by type of prolapse mesh (transvaginal or sacrocolpopexy) or type of sling mesh, although this could be due to smaller numbers in this exploratory subanalysis. Recent literature suggests that women who undergo combined SUI and prolapse mesh revision surgeries have increased risk of complications compared with women with prolapse or SUI mesh alone ( P = 0.045) 34 . This needs to be considered by patients and surgeons during operative planning because the incidence of serious complications at 6 months was higher (7%) for combined mid‐urethral sling and prolapse mesh surgery compared with mid‐urethral sling alone (3.5%) 35 .…”

“…Recent literature suggests that women who undergo combined SUI and prolapse mesh revision surgeries have increased risk of complications compared with women with prolapse or SUI mesh alone (P = 0.045). 34 This needs to be considered by patients and surgeons during operative planning because the incidence of serious complications at 6 months was higher (7%) for combined midurethral sling and prolapse mesh surgery compared with mid-urethral sling alone (3.5%). 35 Finally, six of these patients required a second mesh removal and, although too small for meaningful subanalysis, this is also an area of interesting future work to examine risk factors for second surgery and the impact of this on improvement.…”

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications

“…A total of 15 single-cohort studies of fair and poor quality evaluated mesh erosion preoperatively and postoperatively; 11 [17][18][19]22,[33][34][35][36][37][38]49 report on partial mesh removal, and four 3,43,45,50 report on total mesh removal. The single-group studies all implied resolution of mesh erosion postoperatively, but very few considered this a primary outcome, and postoperative statistics were lacking.…”