Sling incision is not always sufficient: A case series

Philippe E Zimmern; Himanshu Aggarwal; Feras Alhalabi

doi:10.4103/UROS.UROS_21_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 29 | Issue : 4 | Page : 198-201

Sling incision is not always sufficient: A case series

Philippe E Zimmern¹, Himanshu Aggarwal², Feras Alhalabi¹
¹ The University of Texas Southwestern Medical Center, Dallas, TX, USA
² Baptist Medicine Center South, Montgomery, AL, USA

Date of Web Publication

23-Jul-2018

Correspondence Address:
Philippe E Zimmern
The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_21_18

Abstract

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.

Keywords: Bladder outlet obstruction, sling excision, sling incision

How to cite this article:
Zimmern PE, Aggarwal H, Alhalabi F. Sling incision is not always sufficient: A case series. Urol Sci 2018;29:198-201

How to cite this URL:
Zimmern PE, Aggarwal H, Alhalabi F. Sling incision is not always sufficient: A case series. Urol Sci [serial online] 2018 [cited 2023 Oct 2];29:198-201. Available from: https://www.e-urol-sci.com/text.asp?2018/29/4/198/233942

Introduction

Although mid-urethral sling (MUS) is the most commonly performed procedure for female stress urinary incontinence (SUI),^[1],[2] it remains a sling procedure which, as such, can be fraught with secondary complications, including lower urinary tract dysfunction, vaginal pain, and dyspareunia. There is available information on postoperative urinary retention rate after MUS which has been reported as high as 25%–43%.^{[3],[4],[5],[6]} Persistent voiding dysfunction beyond 4 weeks has also been reported in various studies, including a randomized controlled trial (trial of MUS [TOMUS]) by the Urinary Incontinence Treatment Network group.^{[4],[5],[7],[8]} Other complications of MUS have also been described, including vaginal exposure ranging from 3% to 21%,^[5],[9] dyspareunia/vaginal pain 3% to 8%,^[5],[9] and worsening/persistent urgency/urgency urinary incontinence (UUI) 10% to 14% of patients.^[5],[10] In the E-TOMUS, MUS patients were found to be at continuous risk of mesh exposure with 2% additional patients developing sling exposures between 2 and 5 years of follow-up.^[11]

Postoperative voiding dysfunction and the possibility of bladder outlet obstruction (BOO) from MUS are issues not always easy to confirm clinically, despite the accepted tenet that the new onset of voiding dysfunction after a sling should raise concern for BOO.^[12] Several studies have described a variety of surgical techniques to relieve obstruction including urethral dilation, sling stretching, sling incision, partial sling excision, and urethrolysis, with variable outcomes ^[13],[14] Among these different techniques, sling incision offers the least invasive approach, with a timing ranging from 3 to 12 months after MUS placement.^[15] The goal is to relieve the obstruction while preserving some continence. However, there are limited data comparing the merit of this “minimalistic” approach against a more involved approach involving suburethral sling excision or a more complete urethrolysis ^[16] to definitively address the obstructive process. Furthermore, once the MUS incision has been done, it is conventionally assumed that BOO has been relieved, and so, these patients are generally considered “unobstructed.” For this reason, very little information is known regarding persistent lower urinary tract symptoms (LUTSs) following just a sling incision. A recent series of women seen after MUS incision who experienced residual LUTS, vaginal pain/dyspareunia, and/or vaginal exposure of sling mesh called our attention to this often overlooked condition.

The purpose of this study was to review the various erroneous diagnoses assigned to these women after MUS incision, including idiopathic bladder overactivity, and to report herein our approach to evaluation and mid-term outcome after MUS excision in these women.

Materials and Methods

We reviewed an institutional review board approved database of consecutive women who underwent MUS removal from 2006 to 2015. Inclusion criteria included women who presented with continued LUTS, vaginal pain/dyspareunia, and/or recurrent vaginal extrusion of MUS after a prior MUS incision at other institutions. Patients with combined vaginal mesh removal along with MUS removal and with more than one MUS removal were excluded. All data originated from an electronic medical record and were reviewed and updated by a neutral investigator not involved in patient care (HA).

Data collection included demographics, presenting symptoms, physical examination findings, prior procedures including timing and type of MUS placement, timing of MUS incision, other diagnoses assigned to patients along with other treatments done before presentation to our clinic, and outcome after MUS excision. Preoperative evaluation after MUS incision and before consideration for MUS excision included voiding cystourethrogram (VCUG), translabial ultrasound [Figure 1], and/or multichannel urodynamics as indicated. All women underwent vaginal excision of the suburethral portion of the MUS by one surgeon (PZ) with an already reported technique.^[17]

Figure 1: Translabial three-dimensional ultrasound reconstruction demonstrating the course of a transobturator tape with left- and right-sided arms separated by a groove at the 5–6 o'clock position inferior to the urethral lumen where the prior incision took place. The operative note of this patient did not detail the site of the mid-urethral sling incision

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Resolution of pain and dyspareunia was defined as complete resolution meaning being pain-free and with no discomfort during intercourse. Urinary obstruction was determined by subjective voiding symptoms, VCUG findings, and urodynamic pressure-flow testing.^[18] Continence or dry was defined by the patient reporting no or rare episodes of SUI which were not bothersome. Descriptive statistics were used to analyze the data.

Results

From 2006 to 2015, 18 out of 23 women who had MUS incision before presenting to our clinic were identified from a database of 373 patients who underwent one vaginal suburethral MUS excision only. Mean age was 55 + 12 years, with a mean body mass index of 29 + 7. Median time from initial MUS placement to sling incision at outside facilities was 12 months (range 1–108).

After sling incision, several patients were treated for conditions later on attributed to their residual sling but not suspected at the time by their treating team. In particular, four patients were treated with anticholinergic medications for overactive bladder/UUI, and one of them subsequently received a sacral neuromodulator. Four patients were treated with anticholinergic medications and diagnosed with pelvic pain: one of them underwent diagnostic laparoscopy to exclude endometriosis, one received pelvic floor therapy without any relief, and one also had persistent SUI but failed bulking agents. Two patients were diagnosed with voiding dysfunction, with one on clean intermittent catheterization (CIC).

Preoperative evaluation, before sling excision by us, included standing VCUG in 16 women (with mid-urethral kinking/distortion found on lateral voiding views in 6), translabial ultrasound in 2 [Figure 1], and multichannel urodynamics confirming obstruction ^[18] (4) and Valsalva voiding (2).

Indications for MUS excision included persistent obstructive symptoms, alone (3) or along with pain (2), persistent vaginal pain along with dyspareunia (9), recurrent vaginal exposure causing dyspareunia (2) [Figure 2], worsening UUI (1), and mixed urinary incontinence (1).

Figure 2: Vaginal extrusion of mid-urethral sling

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Median time from MUS incision to MUS excision was 55 months (range 5–146). Type of sling included transobturator sling (8), retropubic sling (6), and minisling (4). Median follow-up after MUS excision was 12 months (6–45 months).

All women with exposure (2) and obstruction (5) were cured including the one on CIC before who resumed normal voiding after MUS excision. Vaginal pain and dyspareunia improved in 8 of 11 women and UUI improved in 1. Three women had persistent bothersome SUI and 1 developed bothersome recurrent SUI. Two women with SUI were treated satisfactorily with bulking agents, one with rectus fascial sling, and one with bulking agent followed by a rectus fascial sling.

Discussion

This case series on sling excision after prior sling incision alerts to the fact that a subset of women may experience residual LUTS including UUI, obstructive voiding symptoms, vaginal extrusion, and/or pain/dyspareunia after MUS incision. Because of the prior history of MUS incision, it is commonly assumed by the treating team that the MUS is not causing that persistent symptomatology. There is typically a substantial delay in recognition that the incised MUS can be causative of these residual symptoms. During that phase, a range of therapies have been offered to these women with no durable benefit. Therefore, it is important to recognize that not all MUS incisions will be successful in relieving LUTS or pain/dyspareunia and that, following detailed evaluation and possible specialized testing, MUS excision may have to be considered in these women with residual symptomatology.

By design, any sling regardless of its origin (synthetic, cadaveric, allograft, and autologous) may induce some degree of bladder outflow obstruction (BOO) to be effective.^[19] When this occurs, de novo storage and/or obstructive symptoms can develop. The implications of a postoperative diagnosis of BOO are significant because it means that a procedure to either loosen the sling or remove it suburethrally needs to be contemplated fairly soon to improve voiding and avoid the risk of bladder wall damage; however, this needs to be done while trying to maintain the urinary continence level generally achieved by the MUS placement. Studies have shown that preoperative parameters such as patient demographics and urodynamic findings do not predict which patients are more likely to develop these symptoms. However, one study reported that patients with preexisting voiding symptoms, retropubic sling type, and concurrent prolapse surgery were more likely to need MUS revision.^[20]

Many authors have recommended sling incision as the preferred method of managing these women because of fear of recurrence of SUI along with the fact that it offers a minimally invasive option. However, the data on MUS incision outcome are limited and based on short follow-up. One study reported that out of 1175 patients who underwent placement of a tension-free retropubic mesh sling, 1.9% underwent sling release for voiding dysfunction and/or urge urinary incontinence. All patients with voiding dysfunction had resolution, with 13% developing recurrent SUI.^[21] In a recent study on 3300 women who underwent MUS placement, about 3% patients underwent sling revision at follow-up of 8 months.^[9] However, the follow-up was at 6 weeks only. Another study compared outcomes after sling incision, suburethral sling excision, or complete retropubic urethrolysis after MUS in 44 patients. Overall 93% patients had one of these three techniques performed for voiding dysfunction and 73% experienced resolution of symptoms. SUI recurred or persisted in 34% of patients. There was no difference in outcomes between the three techniques.^[16] However, this study offered a follow-up on only three-quarter of the patients. Some authors have recommended that a midline incision within a year of MUS placement may be more effective than a late incision after a year of MUS placement as far as relieving the obstructive symptoms (91% vs. 71%, P = 0.01), with no difference noted between early and late sling incision for recurrent SUI.^[22] However, this study did not report on outcomes of these patients beyond 1 year.

We report our experience in 18 women who continued to have symptoms after MUS incision. These symptoms were assigned to a variety of differential diagnoses, which in turn prompted a range of therapies that were of no benefit to these women as their original MUS was still the source of their symptomatology. A major limitation of the current literature on sling incision is that the data on how many patients improve after sling incision are unknown as we only see women who are referred or self-referred themselves to us after failed treatments. In addition, the reported number of patients requiring sling excision or urethrolysis is underreported. In a large nationwide study of 9000 patients who underwent tension-free vaginal tape, 50 (0.6%) underwent MUS incision procedure for urinary retention. Out of those, 49% were completely cured, but 12% had persistent retention requiring urethrolysis.^[23] In another recent study, about 70% of patients reported partial or complete improvement after sling revision.^[9] To the best of our knowledge, there is no study describing the incidence of vaginal pain/dyspareunia after MUS and its resolution/persistence after MUS incision alone. We observed that 11 women reported persistent dyspareunia/vaginal pain after MUS incision. Eight of these 11 improved after complete MUS excision at a median follow-up of 12 months. Some of these patients were subsequently referred to pelvic floor therapist for further management.

Conclusions

This is a retrospective series of women who remained symptomatic after MUS incision and were assigned incorrect diagnoses. The practicing provider should be vigilant of continued symptoms in these women, consider further investigations to determine if there is a link with the original sling placement, and if so, consider MUS excision. MUS excision can provide substantial relief in many of these women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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