Hypothesis / aims of study
Mid-urethral sling (MUS) implantation is the gold standard treatment for stress urinary incontinence (SUI) in women after failure of conservative therapy. However, MUS can be associated with pelvic pain occurrence in 0% to 30% of cases. Surgical removal of mid-urethral slings (MUS) for chronic pelvic pain can improved pain in 68% of cases but is associated with a risk of UI recurrence. Management of UI recurrence in those cases has been poorly studied. Our objective was to report the management and functional outcomes of UI recurrence after MUS removal
Study design, materials and methods
We conducted a retrospective review of medical records for all women who underwent partial or total removal of their MUS (TOT or TVT) between November 2004 and February 2018 for chronic post-operative pain in a single tertiary-reference center.
Patients were divided into the transobturator tape group and the tension-free vaginal tape (TVT) group. TVT slings were removed by combining a transvaginal approach with transperitoneal laparoscopy while TOT slings were removed through transvaginal and groin approach as previously described.
Patients were seen at two months post-operatively to assess persistence of pelvic pain and the recurrence of UI. In case of UI recurrence, SUI was differentiated from urge UI (UUI) and mixed UI (MUI) by symptoms, clinical examination and, if needed, urodynamics.
The primary objective of the study was to evaluate the management of UI recurrence after tape removal. The primary outcome measure was the necessity to perform another surgery to treat recurrent SUI. Secondary objective was to report the rates of recurrent SUI after tape removal and the rates of subsequent surgery
Eighty nine women were included in the study. Thirty seven (41.5%) had a TVT removed. Of them, 19 (51.3%) had only ipsilateral sling removed, 15 (40.5%) underwent bilateral removal and 2 (5.4%) underwent only vaginal section of the sling. Fifty women (56.1%) had a TOT removed.
Median follow-up was 41.4 months [0.9-138.8]. Urinary incontinence recurred after tape removal in 58.4 % (n=52) of cases. In the TVT group, 51.3% (n= 19) of patients experienced UI recurrence. UI occurred in 62% (n =31) of patients in TOT group and for the two patients who underwent total removal of both slings.
Seventeen patients (32.6%) refused to undergo subsequent treatment: 4 had mild UI with no need for conservative or surgical therapy and 7 were eligible for surgery but refused because of being afraid of pelvic pain recurrence. The reasons for no treatment were not known in 6 cases. Fourteen patients (26.9%) were managed and cured with conservative therapy alone. Overall 21 patients (40.3%) underwent UI surgery within a median interval of 10.4 [3.8-73.1] months since tape removal. Of them, 18 (85.7%) were treated for recurrent SUI. Most of them underwent TVT implantation (n= 10, 47.6%). After this first surgical treatment of UI recurrence, 28.6% of patients (n=6/21, 2 TVT, 3 TOT and 2 TOT and TVT) were still incontinent. Overall continence rate at last follow-up was 82% (73/89).
Among patients with UI recurrence, 13 (25%) were still painful after sling removal with a mean pain NRS of 6.1 [5-7]. Two had had a TVT removed, 10 a TOT and 1 had TOT and TVT removed. Of them, 69.2% (n= 9) refused to be treated of their UI.
Interpretation of results
After MUS removal for pelvic pain, UI recurrence occurred in 58.4% of patients. Most patients may be manage without any treatment or with conservative measures only. However, more than 40% of them will undergo redo surgery with a low risk of pain recurrence. Continence was achieved for 82% of patients.