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Management of Urinary Incontinence Following Suburethral Sling Removal: Beyond the Abstract

Stress Urinary Incontinence (SUI) affects 25%-50% women in the United States1. Surgical approaches are used to treat SUI when conservative approaches are unresponsive. The most common in the United States is Mid-Urethral Sling (MUS) placement2; however, complications can arise following MUS placement and 2.7%-3.7% of patients may require midline sling incision. While the need to anti-incontinence procedures for recurrent SUI has been relatively low after midline sling incision3, this approach is not appropriate for all indications due to paucity of data on incontinence outcomes and management following SSR. Thus, the primary aim of this study is to evaluate urinary incontinence outcomes following synthetic suburetrhal sling removal in women. 

The authors in this study reviewed a prospectively maintained database of 360 patients who underwent transvaginal suburethral sling removal from 2005 to 2015. Exclusion criteria included patients with: neurogenic bladder, nonsynthetic or multiple slings, prior mesh for prolapsed, concomitant surgery during sling excision, urethral erosion or fistula, postoperative retention or less than 6-month follow up. The outcomes measurement for this study were: patient Demographics, type of sling placed, presenting symptoms and indications for removal, UDI-6 and ILQ-7 scores, preoperative testings, and time to SSR following initial placement. Patient reported outcomes were also reported. Incontinence outcomes were stratified by type (SUI, UUI, or MUI), and further sub categorized by whether symptoms were persistent or de novo in nature.. Subsequent management was evaluated including nonoperative treatment, minimally invasive intervention or more invasive surgery,  

In total, 99 patients were included in the analysis (mean follow up after SSR was 23 months (range 6 to 114). 27 patients (27%) denied any subjective leakage after SSR alone, while 72 (73%) experienced some degree of post-SSR incontinence after removal. Stress predominant urinary incontinence occurred in 26 patients, which was persistent in 7 and de novo in 19, urge predominant incontinence occurred in 14, which was persistent in 6 and de novo in 8, and mixed urinary incontinence occurred in 32, which was persistent in 13 and de novo in 19. The success rate following a single minimally invasive intervention after suburethral sling removal was 81%, 86% and 75% in patients with stress predominant, urge predominant, and mixed urinary incontinence, respectively.

In conclusion, patients who undergo SSR for a variety of complications or failure may experience urinary control, or de novo or persistent incontinence with a higher predilection for SUI or MUI. However, success rate after a single minimally invasive intervention following SSR removal was 75% to 86%.This shows that patients who undergo sling removal can maintain favorable urinary control. Some limitations that the authors noted were data may not be generalized due to being at a single institution, and measure of success was determined by subjective patient reported symptoms. Despite these limitations, the prospective nature, large cohort, and homogenous patient populations strengthens the validity of this study. 

Written by: Zhamshid Okhunov, MD Department of Urology, University of California, Irvine

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References:

1. Chong EC, Khan AA and Anger JT: The financial burden of stress urinary incontinence among women in the United States. Curr Urol Rep 2011; 12: 358.

2. Chughtai BI, Elterman DS, Vertosick E et al: Midurethral sling is the dominant procedure for female stress urinary incontinence: analysis of case logs from certifying American urologists. Urology 2013; 82: 1267