Background
Midurethral slings have become the preferred surgical treatment for stress urinary incontinence. Midline transection of midurethral sling for dysfunctional voiding is an effective treatment and also has a low rate of recurrent stress incontinence. Recurrent stress incontinence after sling revision for pain and mesh exposure has not been well defined. It is therefore difficult to counsel patients on risk of recurrent stress incontinence when sling revision is performed for pain or mesh exposure.
Objective
We examined the rate of postoperative stress incontinence after midurethral sling revision for the indication of mesh exposure or pain, as well as postoperative pain and urinary urgency.
Study Design
This is a retrospective cohort of 245 patients undergoing a vaginal midurethral sling revision in a 10-year period for the indication of mesh exposure or pain. Preoperative indication for revision, baseline characteristics, and preoperative reports of stress incontinence, pain, and urgency were collected. The type of sling revision was then categorized into partial or complete removal. A partial removal of the sling was defined as removing only the portion of sling exposed or causing pain. A complete removal of the sling was defined as vaginal removal of sling laterally out to the pubic rami. Subjective reports of stress incontinence, pain, and urgency at short-term (16 weeks) and long-term (>16 weeks) follow-up visits were gathered. The primary outcome of the study was recurrent stress incontinence.
Results
In our cohort of 245 women who underwent midurethral sling revision, 94 patients had removal for mesh exposure (36 partial and 58 complete) and 151 had removal for pain (25 partial and 126 complete). All patients had a short-term follow-up with a mean time of 5.9 ± 2.8 weeks and 69% patients had long-term follow-up with a mean time of 29.1 ± 17.7 weeks. No differences were seen in preoperative reports of stress incontinence, urgency, or pain in either group. In the patients with revision for mesh exposure with no preoperative stress incontinence, there was greater postoperative stress incontinence with complete vs partial removal of sling at short-term (14% vs 42%, P = .03) and long-term (7% vs 59%, P = .003) follow-up. In the patients with revision for pain with no preoperative stress incontinence, there was no statistically significant difference in recurrent stress incontinence with complete sling removal at long-term follow-up (22% vs 56%, P = .07). In the patients with midurethral sling revision for pain, 72% of partial and 76% of complete sling removal had resolution of pain postoperatively ( P = .66). No difference was seen in postoperative reports of urgency or pain improvement in either group between partial or complete sling removal.
Conclusion
In women undergoing midurethral sling revision for mesh exposure, complete sling removal resulted in higher recurrent stress incontinence compared to partial sling removal. For the indication of pain, both partial and complete sling removal improved pain in the majority of patients, but there was no statistically significant difference in recurrent stress incontinence.
Introduction
Synthetic midurethral slings (MUS) have become the preferred surgical treatment for stress urinary incontinence (SUI). Complications including pain, exposure, and dysfunctional voiding often require procedures for the revision of MUS. The most well-studied MUS revisions are performed for the indication of voiding dysfunction. A simple midline transection of the MUS has been found to be a successful method of resolving voiding dysfunction with almost 100% success rates in both retropubic and transobturator slings. Recurrence of SUI after midline transection of MUS for voiding dysfunction has been found to be between 13-24% at 5 years in both types of slings.
MUS revision for other indications such as pain, dyspareunia, and mesh exposure is often a different procedure than sling incision for voiding dysfunction, and may include partial or complete vaginal excision of the sling. Mesh erosion has been found to be the more common long-term indication for a MUS revision procedure with a 2.5% cumulative 9-year risk vs only 1.3% cumulative risk for MUS revision for urinary retention or voiding dysfunction. However, there are only a few studies that document the risk of recurrent SUI after MUS revision for vaginal mesh exposure or vaginal pain and none of these studies compare recurrent SUI rate between patients with complete vs partial vaginal excision of the MUS. It is therefore difficult to counsel patients on the risk of recurrent SUI when MUS revision is performed for these indications.
Therefore, the objective of this study was to determine the risk of postoperative SUI in a cohort of patients undergoing MUS revision for the indications of mesh exposure or pain. Our secondary objectives were to look at de novo urinary urgency, postoperative pain, and reoperation rate after MUS revision for mesh exposure or pain.
Materials and Methods
This is an institutional review board–approved retrospective cohort of patients who underwent a vaginal MUS revision procedure at our institution from May 2004 through May 2014 for the indication of mesh exposure or pain. Patients who previously underwent a pubovaginal sling, had bladder or urethral mesh erosion, had concomitant incontinence surgery, or had an abdominal revision procedure were excluded from the study. Patients with an indication of voiding dysfunction for MUS revision were also excluded. Only women with vaginal MUS revision for the primary indication of vaginal mesh exposure or pain/dyspareunia were included.
We reviewed electronic medical records for the included patients, collecting data on baseline characteristics of age, race, body mass index, concomitant surgery, and smoking, as well as preoperative indication for revision procedure and preoperative reports of urinary incontinence, pain, and urgency. Preoperative visits were reviewed for reports of preoperative urinary incontinence, vaginal pain, or urinary urgency: symptoms that are standardly asked about and recorded at preoperative and postoperative visits. The primary indication of the MUS revision procedure was determined from operative note indication and primary patient report at time of preoperative visit. Patients’ primary symptom determined which indication category they would fall into when both indications being studied were present. The type of sling revision was categorized into partial removal of sling or complete removal of sling, based on descriptions of the procedures in the operative reports. A partial removal of the sling was defined as excising only the portion of the sling that was exposed or causing pain. The amount of MUS removed was not standardized between surgeons. A complete removal of the sling was defined as complete excision of both arms of the sling vaginally from pubic ramus to pubic ramus. Postoperative visits were reviewed for subjective reports of urinary incontinence, pain, and urgency at short-term (≤16 weeks) and long-term (>16 weeks) visits as well as reoperation for urinary incontinence. Patients are seen at 4-6 weeks, 3 months, 6 months, and 1 year postoperatively at our institution after MUS revision. Since most patients do not return after the initial 1-2 postoperative visits, we chose 16 weeks as the cut-off point for long-term follow-up, for which many patients may not return. The primary outcome of the study was recurrent SUI as reported in postoperative follow-up visits. The secondary outcomes were postoperative pain, de novo urinary urgency, and reoperation rates.
The χ 2 test for categorical variables and t test for continuous variables were used to compare data between partial and complete removal in MUS revision groups. Statistical significance was defined as P ≤ .05. Statistics were performed using statistical software (Stata, Release 13; StataCorp, College Station, TX). Study data were collected and managed using research electronic data capture (REDCap) tools hosted at Vanderbilt University. REDCap is a secure, World Wide Web–based application designed to support data capture for research studies.
Materials and Methods
This is an institutional review board–approved retrospective cohort of patients who underwent a vaginal MUS revision procedure at our institution from May 2004 through May 2014 for the indication of mesh exposure or pain. Patients who previously underwent a pubovaginal sling, had bladder or urethral mesh erosion, had concomitant incontinence surgery, or had an abdominal revision procedure were excluded from the study. Patients with an indication of voiding dysfunction for MUS revision were also excluded. Only women with vaginal MUS revision for the primary indication of vaginal mesh exposure or pain/dyspareunia were included.
We reviewed electronic medical records for the included patients, collecting data on baseline characteristics of age, race, body mass index, concomitant surgery, and smoking, as well as preoperative indication for revision procedure and preoperative reports of urinary incontinence, pain, and urgency. Preoperative visits were reviewed for reports of preoperative urinary incontinence, vaginal pain, or urinary urgency: symptoms that are standardly asked about and recorded at preoperative and postoperative visits. The primary indication of the MUS revision procedure was determined from operative note indication and primary patient report at time of preoperative visit. Patients’ primary symptom determined which indication category they would fall into when both indications being studied were present. The type of sling revision was categorized into partial removal of sling or complete removal of sling, based on descriptions of the procedures in the operative reports. A partial removal of the sling was defined as excising only the portion of the sling that was exposed or causing pain. The amount of MUS removed was not standardized between surgeons. A complete removal of the sling was defined as complete excision of both arms of the sling vaginally from pubic ramus to pubic ramus. Postoperative visits were reviewed for subjective reports of urinary incontinence, pain, and urgency at short-term (≤16 weeks) and long-term (>16 weeks) visits as well as reoperation for urinary incontinence. Patients are seen at 4-6 weeks, 3 months, 6 months, and 1 year postoperatively at our institution after MUS revision. Since most patients do not return after the initial 1-2 postoperative visits, we chose 16 weeks as the cut-off point for long-term follow-up, for which many patients may not return. The primary outcome of the study was recurrent SUI as reported in postoperative follow-up visits. The secondary outcomes were postoperative pain, de novo urinary urgency, and reoperation rates.
The χ 2 test for categorical variables and t test for continuous variables were used to compare data between partial and complete removal in MUS revision groups. Statistical significance was defined as P ≤ .05. Statistics were performed using statistical software (Stata, Release 13; StataCorp, College Station, TX). Study data were collected and managed using research electronic data capture (REDCap) tools hosted at Vanderbilt University. REDCap is a secure, World Wide Web–based application designed to support data capture for research studies.
Results
In all, 245 patients were identified as having undergone vaginal MUS revision for the indication of vaginal mesh exposure or pain/dyspareunia from May 2004 through May 2014. Of these patients, 94 patients were identified as having undergone MUS revision for the indication of mesh exposure; 36 (38%) were partial and 58 (62%) were complete removal of the sling. The 151 remaining patients were identified as having MUS revision for the indication of pain; 25 (17%) had partial and 126 (83%) had complete removal of the sling. Baseline characteristics of women undergoing MUS revision for mesh exposure are seen in Table 1 and for pain in Table 2 . All patients had a short-term follow-up visit completed with a mean follow-up time of 5.9 weeks. Approximately 69% of patients had a long-term follow-up visit with mean follow-up time of 29.1 weeks. Baseline characteristics did not differ in those who did and did not return for long-term follow-up (data not shown).
| Parameter | All patients, n = 94 | Partial removal, n = 36 | Complete removal, n = 58 | P value |
|---|---|---|---|---|
| Age, y, mean ± SD | 55.2 ± 12.1 | 59.0 ± 12.7 | 55.2 ± 12.1 | .019 |
| Parity, mean ± SD | 2.1 ± 1.2 | 2.1 ± 1.2 | 2.1 ± 1.2 | .779 |
| BMI, mean ± SD | 29.5 ± 6.9 | 31.1 ± 7.8 | 28.6 ± 6.1 | .111 |
| White race (%) | 89 (95) | 32 (89) | 57 (98) | .05 |
| Smoker (%) | 23 (24) | 8 (22) | 15 (26) | .690 |
| Diabetes (%) | 16 (17) | 6 (17) | 10 (17) | .943 |
| Preoperative SUI (%) | 36 (38) | 14 (39) | 22 (38) | .926 |
| Preoperative pain (%) | 76 (81) | 26 (72) | 50 (86) | .094 |
| Preoperative urge (%) | 45 (48) | 17 (49) | 28 (48) | .978 |
| Long-term visit (%) | 56 (60) | 24 (67) | 32 (55) | .270 |
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